LIBRARY OF CONGRESS. 

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UNITED STATES OF AMERICA. 






















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GUIDE 

TO THE 

Examination of Urine, 

WITH SPECIAL REFERENCE 

TO THE 

DISEASES OF THE URINARY APPARATUS, 

BY 

K.B.HOFFMAN, and R. ULTZMANN, 

Professor at the University Docent at the University 

OF GRAZ. OF VIENNA. 



FROM THE SECOND EDITION, 

TRANSLATED AND EDITED BY 

F. FORCHHEIMER, M. D., 

PROFESSOR OF MEDICAL CHEMISTRY AT THE MEDICAL COLLEGE 
OF OHIO, CINCINNATI. 



1 



TH 



WITH ILLUSTRATIONS. 






CINCINNATI : ^>> WASHV^^ 

PETER G. THOMSON, Publisher,, ^J! -^ 

179 Vine Street, 
1879. 






^ #?, 



** 



COPYRIGHT 

1879. 

PETER G. THOMSON- 



INDEX 









PAGE. 


Acetone 




• • 


71. 


Albumen 


• 


• 


59> 135. 


Albuminuria . 




• • 


154. 


Alcohol 


• 


• 


71. 


Alkalies, 








Chlorides 




• • 


Si. 


Carbonates 


# 


. 


. 84. 


Phosphates 




• 


S3- 


Sulphates 


• 


. 


. 57. 


Urates 




• 


88. 


Allantoine 




. . 


41, 81. 


Ammonia 


. 


. 


. 58. 


Ammonium, Carbonate 




. 


81. 


Magnesium 


Phosphate 


. 100. 


Urate 




. 


90. 


Amyloid, Kidney . 


• 


• 


. 164. 


Bacteria 




. 


114, US- 


Bilharzia . 


, 


. 


119, 173, 181. 


Biliary Acids . 




• • 


79- 


Biliprasine . 


• 


• 


. 77- 


Bilirubine 




• 


77- 


Blood-coloring Matters 


• 


74, 75. 


Blood Corpuscles 




. 9 


106. 



IV. 



INDEX. 



Calcium, Carbonate 


PAGE. 

. IOO. 


Oxalate 


92. 


Phosphate 


. 54- 


Calculi, Renal . 


169. 


Vesical . . • 


. 193. 


Cancer . 


117. 


Carbamide . 


34, 81. 


Casts . 


108. 


Chlorine, Estimation of 


137. 


Chyluria .... 


26. 


Color ..... 


. 27. 


Coloring Matter, Blood 


. 74, 75- 


Biliary 


- 77- 


Urine 


44. 


Vegetable 


. 74- 


Composition of Urine 


32. 


Concretions . 


120, 193. 


Consistency .... 


20. 


Creatinine , 


• 133. 


Cystine ..... 


93. 


Cystitis . 


. 183. 


Diabetes .... 


25. 


Distoma . 


181, 119. 


Earthy Phosphates . . . 


54. 


Echinococci 


119, 173. 


Epithelia .... 


102. 


Estimation of Acidity 


. 127. 


Albumen . . 


135. 


Chlorine . . 


• 137. 


Creatinine 


133. 


Iodine 


. 84. 


Nitrogen 


134. 


Phosphoric Acid 


. 138. 



INDEX. 



Estimation of Sulphuric Acid 


PAGE. 
HO. 


Sugar 


. 135- 


Urea 


128. 


Uric Acid . 


. 132. 


Ethyl-Diacetic Acid . 


71. 


Fats ..... 


. 8l. 


Fermentation 


. 84, 96. 


Fluorescence 


. 29. 


Fibrine .... 


60. 


FlBRINURIA .... 


60, I9O, 9O. 


Fungi . 


114. 


Galacturia • 


• 97. 


Globuline . . • 


66, 


Glycosuria .... 


. 70. 


Gravity, Specific . . 


22. 


Haematoidine . • • 


. 192. 


Haematuria . • • 


173. 


Haemine Crystals . . . 


- 75. 


Haemaglobine . 


75- 


Hippuric Acid 


. 50. 


Hydruria 


25. 


Hyperaemia of the Kidney 


154. 


Indican .... 


46, 47. 


Indigo .... 


47. 


Indol .... 


49- 


Inorganic Substances 


32, 51. 


Inosit .... 


71. 



Kyesteine 



116. 



Lactic Acid 



5i» 81. 



VI. 


INDEX. 




PAGE. 


Lactosuria 


• • • 


• 


71. 


Leptothrix 


• • • 




114. 


Leucine 


• • • 


• 


. 71. 95- 


Magnesium Phosphates . 




99. 


Metal Salts 


• • • 


• 


83. 


Methaemoglobine 


• • a 




75. V6. 


MlCROCYTES 


• • • 


• 


108. 


Mucus 


• • 




101. 


Murexide Test 


• • • 


• 


40. 


Neoplasms 


• • 




• 188. 


Nephritis 


• • • 


• 


157. 


Nitrogen 


• • i 




. 134. 


Nubecula 


. 


• 


85. 


Odor 


• • • 


# 


30. 


Oidium 


• • 




. 116. 


Oxalic Acid 


• • 


• 


50. 


Oxaluric Acid 


. « 




. 50. 


OXYMANDELIC ACID 


. 


• 


72. 


Papillary Cancer 


• • 




. 117. 


Paraglobuline 


• • • 


. 


60. 


Penicillium 


. . 




. 116. 


Peptones 


• • 


, 


66. 


Phenol-Forming Substance 




. 50. 


Phosphates 


• • • 


, 


• 53, 138. 


Prostatitis . 


• • 




. 194. 


Pus 


• • • 


• 


. 89, 105. 


Pyelitis 


• • 




. 166. 


Pyrocatechine 


• • • 


• 


68. 


Quantity 


• a • 


• 


22. 


Reaction 


• • • 


• 


30 



INDEX 



Saccharomyces 
Salicylic Acid 

SARCINiE 

Sediments 

Solid Residue 

Spectrum 

Spermatorrhcea 

Spermatozoa 

Sugar 

Sugar of Milk 

Sulphide of Hydrogen 

Sulphates 

Sulphonic (di.) Acid 

Transparency . 
Triple-Phosphate . 
Turbidity 
Tyrosine 



Urates 

Urea 

Uric Acid 

Urinometer 

Urobiline 

Uroerythrine 

Uroglaucine 

Urohaematine 

Urophaeixe 

Uroxanthine 

Urrhodine 



Xanthine 
Zooglea 



Vll. 



. 


115. 


. 


84 


. 


115. 


. 


87 


24, 


128. 


. 


30. 


. 


194. 


. 


116. 


50, 67, 


135. 


. 


71. 


. 


83. 


. 


57. 


50, 


140. 


. 


29. 


. 


100. 


. 


30. 


7h 


95- 


. 41 


SS. 


33> 


128. 


38, 9 J > 


132. 


. 


23. 


. 


73. 


. 


73. 


. 


46. 


46, 


73. 


. 46, 


47. 


46, 


47. 


. 46, 


47- 




50. 


c 


115. 



PREFACE. 



In bringing this little work before the medical public, the 
translator has been encouraged by the fact of its popularity on 
the Continent, and its nearly universal adoption by the Ger- 
man high-schools. Now that the second German edition has 
appeared, considerably altered from the first, as well as en- 
larged, he no longer hesitates in bringing it before the pro- 
fession of this country. As the authors state in the preface 
to the first edition, this book is not intended for the physi- 
ological chemist, nor for him who is going to make animal 
chemistry a specialty; neither does it supply the place of 
many larger works, such as exist in the English language. 
Every test, every method, is brought home to the student 
and physician for use in practice. A great amount of space 
and time is spent upon methods, showing how an examina- 
tion of urine and diagnosis of disease can be most readily 
and quickly made. The book, in every respect, is fully up 
to the times, for which the names of the authors, alone, are 
sufficient guarantee. 



PREFACE. 

The office of the translator has been not only to translate, 
but, also, in several places, to make slight additions or omis- 
sions, being guided therein by his experience as teacher of 
urinalysis in the Medical College of Ohio. In addition, he 
has supplied the illustrations, that have been drawn by his 
student, Mr. W. S. Christopher, and which, he hopes, will 
make the book more attractive, as well as more instructive, 
than it would have been in the German form. 

" May the endeavors to increase the utility of this work 
not be without result." 

F. F. 



INTRODUCTION. 



The results of those processes, usually complicated, which 
go to make up the basis of organic life, are, on the one hand 
the building up of the body; on the other, changes which 
have been collectively termed u retrograde metamorphosis." 
The effete substances which can no longer be utilized by the 
economy are eliminated by the skin and lungs (in the form 
of gas) ; by the intestinal tract and kidneys (either in the form 
of solids or in solution). 

In order to come to a correct conclusion regarding the 
nutrition of the body (the normal or diseased process), 
both the functions of the above named organs and the 
conditions of the excrementitious matter furnished by these 
must be equally carefully examined into. In the healthy 
condition of the organism this is connected with immense 
difficulties and in any material disease becomes entirely 
impossible. 

The physician is compelled to restrict his examination to 
one of these excretions, if he wishes to gain an insight into 
the economy, but he can examine the most important 
excretion — the urine. 

The urine, at least, registers approximately, by means of 
qualitative and quantitative changes the variations of histolog- 
ical processes. In addition, the examination of urine has 
this advantage, that the fluid can be collected without diffi- 



2 INTRODUCTION. 

culty and its analysis, so far as it interests the practicing 
physician, can be carried out by very simple means. 

The kidney, as it is not a lifeless filtering apparatus, will 
be subjected to disease, and as a result of these pathological 
changes, substances will be mixed with the urine whose 
presence alone will lead the physician to a diagnosis of the 
disease. The urine, then, gives us a general insight into the 
condition of the whole body, but especially into the 
condition of the urinary apparatus. In passing, it is only 
necessary to mention, that, on account of the fact, that many 
substances have the peculiarity of leaving the organism after 
having remained in it for a variable length of time, by means 
of the kidney ; the urine is of great importance to the phy- 
siologist, the phamaceutist and in some instances to the 
expert in medico-legal cases. 

The desire to recognize disease from the appearance of 
the urine reaches back into the most remote past of scientific 
medicine. In his precise and objective observation of the 
sick, Hippocrates did not disregard the changes in the urine. 
He taught, in accordance with the condition of other 
sciences, his pupils the semiotic and also, prognostic im- 
portance of these changes. He demonstrated the physical 
properties of urine ; the quantity, color and clearness, the 
cloudy or turbid appearance \ the apparent differences in the 
sediments and referred these to diseases of the urinary 
apparatus. He even tried to show the influence of food and 
drink upon the condition of the urine. 

We therefore find in the descriptions of disease of Greek 
authors, after him, the condition of urine taken into consider- 
ation, without their having deviated from the opinions of the 
great Coic physician. Since Galen developed the teachings 



INTRODUCTION. 3 

of Hippocrates j and treated them systematically, these have 
been considered as absolutely true. Observations on urine 
for a long time did not show any progress. 

Throughout the following centuries rarely is an author 
found, who, through personal observations, added anything 
to these writings. To the Arabian Iben Sina (980 — 1037) 
usually called Avicenna, belongs the credit of having pointed 
out that various external causes, such as fasting, vigils, 
physical and mental exertions, have an influence upon the 
condition of the urine. He also demonstrated that drugs 
taken internally may cause a temporary discoloration of the 
urine. Otherwise the Arabic physicians did nothing of im- 
portance on this subject, notwithstanding the presence of an 
uroscopist at every court throughout the orient. 

The most prominent author on our subject, that lived in 
ancient times or during the middle age, is beyond doubt 
Johannes, called Actuarius, who flourished in the thirteenth 
century at the court of Byzantium. Combining his own 
experience with the observations of the school of Hippocrates- 
Galen, he describes the physiological and pathological 
changes in urine in seven books of his work, "rrspl ovpGw" 
to their most minute details. In addition, he is quite con- 
spicuous on account of his methodical and clear descriptions. 
This production, which exhausted everything that could be 
expected in the then condition of the allied sciences and 
methods, remained so isolate, found so few followers, that 
this division of symptomatology was neglected more and 
more in the time following this work. How far degeneracy 
had taken place, can be seen that it furnished material for 
satirical representations in the Dutch genre pictures, as well 
as for many comedies of Moliere and other poets. 



4 INTRODUCTION. 

As the ideas up to this time, on the chemical composition 
of the urine were highly defective, the external appearance 
only could be considered by all old authors. Real progress 
could only be expected at a time when chemistry and its 
methods of examination had arrived at a certain degree of 
development. With Lorenzo Bellini of Florence this pro- 
gress begins. 

Bellini evaporated urine and observed, that as he again 
added water, the solids would again dissolve, returning 
gradually, step by step, through various intensities of taste 
and color, nearly to the original condition. From this, he 
concluded that the different color and taste of urine 
depended upon the relation the solid constitutents bore to 
the water, a conclusion, upon which, even at the present, 
the scale of colors of Vogel is based. 

Many important chemical discoveries followed soon after 
this. Willis discovered sugar in urine ; Brandt discovered 
phosphorus, which Markgraff stated, came from the phos- 
phates that were contained in the urine. 

Rouelle, the younger discovered urea in 1773 and found 
that calcic carbonate was present in the urine of herbivora, 
as well as a substance related to the flowers of benzoe 
(Hippuric acid). In 1770 Cotugno found albumen in urine, 
in 1798 Cruickshanc connected this discovery with dropsy 
and in 1807 Bright, finally demonstrated the connection 
between diseased kidneys and albuminuria. 

At the same time chemical analyses of gravel and calculi 
were undertaken. Among the many publications of merit, 
on this subject, those of Scheele, Wollaston, Wetzlar and 
Prout must be especially mentioned. 

Two Frenchmen, however, have furthered the develop- 



INTRODUCTION. 5 

ment of uroscopy, to its present point, more than any one. 
The researches of Rayer that are put down in the large 
work " Les maladies des reins, " are the foundations for 
our present knowlege of kidney diseases. Becquerel, the 
son of the celebrated physicist, had for a long time, occupied 
himself with urinalysis under the direction of Andral, and 
in a modest manner gives to him all the credit of having 
furnished the ideas for observations. These observations, 
extending through many years, he published in the work 
"Semiotique des urines." For the thirty years since the 
appearance of this book many observers have devoted 
themselves to this branch, so that, probably no other division 
of zoochemistry has so extensive a literature as this. 

After this short sketch of the development of our subject, 
there remains only a brief discussion of the divisions that 
have been thought necessary. 

After a chapter on the microscopic structure and function 
of the urinary organs, without a knowledge of which, com- 
prehension of disease becomes an impossibility, the physical 
characters and chemical constituents of urine, as far as they 
seem to us important to the practicing physician, are treated of. 
Upon this follows a description of the microscopical part, 
i. e. the sediments of urine. Repetitions will be of advan- 
tage to the beginner, for whom this little work is intended. 

The short key to the method of examination will also be 
of value to the beginner. Finally a description of the simple 
(uncomplicated) diseases of the urinary organs, will be 
found, in so far as they give signs that can be utilized for 
diagnosis. 



CHAPTER I. 
HISTOLOGY OF THE URINARY APPARATUS. 



Fig I. 

A longitudinal section through the 
kidney of a dog ; both blood vessels 
and urine tubes injected. 



I. The Kidney.* 

If a kidney be cut from the papilla to the fibrous capsules, 
two concentric layers become distinctly visible to the naked 
eye ; the striped medulla and the peripheral, more granular 
cortical, the latter surrounding the former. 

If the vessels and uriniferous tubes have previously been 
injected with different colors, other divisions can be made 
upon the section. 

p, Papillary portion ; g, border 
layer of the medulla; r, cortical 
layer. The dark stripes of the 
medulla, h, are bundles of urini- 
ferous tubules, their continuation, 
m 9 into the cortex. The light 
T divisions of the medullary layer, 
b, correspond to the bundles of 
blood-vessels of the border layer. 
The light portions of the cortical 
that are occupied by dots (glom- 
' yeruli), c, demonstrate the position 
of the labyrinth (after Ludwig). 
In the papilla, and in the 
neighborhood above it, the kid- 
' ney seems to be uniformly striped, 
colored only by the mass injected 

*The investigations of Kolliker, Schweigger— Seidel, and Ludwig were taken as 
basis for this description of histological relations. 




8 EXAMINATION OF THE URINE. 

into the urinary tubes; this division is called the papillary- 
layer of the medulla. Above this there is a section 
which is also striped but which already begins to show the 
mass injected into the blood vessels. There can here be seen 
alternate stripes of both injection masses, arranged as radii, 
next to each other. This part is called the border layer of 
the medulla. The third, outer layer, finally, that encloses 
both the others, is called the cortical layer. 

In the cortical layer itself, two substances can be distin- 
guished that are arranged in the same radial way and that 
can be discerned by means of the two injected colors. The 
one is striped, and is colored by the mass that has been forced 
into the urine tubes, and is the direct continuation of the 
fibres of the medulla and is called medullary bundles, 
(pyramids of Ferrein.) The other substance shows granules 
principally, which seem to be colored by the mass injected 
into the blood vessels, and is the so-called labyrinth or 
cortical layer in the strict sense. 

Accordingly we find when we take the microscope, that . 
the papillary layer is made up principally, of straight urinif- 
erous tubules ; the border layer partly of straight uriniferous 
tubules, partly of straight blood vessels; the pyramids princi- 
pally of straight uriniferous tubules, and finally, the labyrinth 
consists partly of convoluted tubules and partly of covoluted 
tubules and tortuous blood vessels. 

This system of blood vessels and uriniferous tubules is 
supported by connective tissue which forms a very sparse 
stroma. This consists of a very fine network of connective 
tissue corpuscles and is better marked in the medullary layer 
than in the cortical. Upon the surface of the kidney the 
stroma condenses into a delicate membrane which is but 



THE KIDNEY. 9 

loosely connected with the fibrous investing membrane. The 
latter consists of ordinary connective tissue with a dense, 
fine, elastic network ; it surrounds the whole kidney, and at 
the hilus, is directly attached to the vessels and the pelvis of 
the kidney. 

The Uriniferous Tubules begin in the labyrinth. Each be- 
gins in the form of a spherical dilatation (Capsula Malpighii). 

1 ' This is continued through a contracted portion (the neck 
of the capsule) into a dilated tube, which takes its course in 
manifold curves towards the medullary portion. When this 
convoluted portion has reached the border layer, in the form 
of a wide tube, it suddenly becomes pointed, and penetrates 
as a straight narrow canal, more or less deeply, into the 
medullary substance (descending or closed limb of the loop) 
turns back in the form of a narrow loop (Henle's loop) and 
runs directly upward towards and into the cortical substance 
(ascending or open limb of the loop)".* 

" Upon returning to the cortex the tubule does not seek 
the exact place from which it came; on the contrary, it seems 
to avoid the labyrinth and lies close to the nearest pyramid 
of Ferrein. Sooner or later it leaves its straight course 
again and enters in the form of more or less angular curva- 
tures, as so-called intermediate portion, between the tortuous 
canals, the labyrinth. From here it returns, forming an arch 
whose convexity is directed towards the convexity of the 
kidney, towards the pyramid of Ferrein, to give up its indi- 
vidual course. The latter is accomplished, in that several 
tubules, coming from various directions to one point, are 
melted together for the formation of a wide and straight 
tube (collecting tubule)." This takes a straight course until 

-The quotation is taken from the classic description of C. Ludwig. (Handbook 
of Histology, Strieker.) 



IO 



EXAMINATION OF THE URINE 



Fig 2. 
Schematic representation of the course of a 
uriniferous tube; human kidney. 

K 



it reaches the papillary portion of the kidney where it unites, 
dichotomously, with neighboring collecting tubules, and so 
on, until the uniting collecting tubules empty, in the form of 
the ductus papillaris upon the surface of the papilla. 

/, Papillary layer; g, 
border layer of the med- 
ullary substance; r, cor- 
tical substance. Capsule 
of glomerulus I, which 
enters into tortuous por- 
tion II through the neck. 
This tapers at the 
boundary between 
medulla and cortical 
into the descending limb 
of the loop III, and, as 
such, goes through Hen- 
le's loop h, into the 
ascending limb of the 
loop IV. To this is 
added the intermediate 
portion V, which, 
through the external 
arch at the top of r, en- 
ters the collecting tubule. 
The collecting tubule 
unites with its neigh- 
bor of the same pyramid 
VII, to form the princi- 
pal tube VIII, and this, 
finally unites with others 
to form the ductus pap- 
illaris IX. 




THE KIDNEY. H 

The walls of the Malpighian capsule, like those of the 
blood and lymph capillaries, are made up of a mosaic of cells. 
The glomerulus, or tuft, is not washed directly by the fluid 
contents of this capsule; this is prevented by a layer of 
cells not distinctly separated from each other, containing 
spherical nuclei, that cover the external surface of the tuft 
of vessels. " From the neck of the capsule to the com- 
mencement of the papillary duct, the wall of the tubule is 
composed of a tunica propria and a layer of epithelium 
resting upon its inner surface." The tunica propria is homo- 
geneous, vitreous, and elastic. 

The epithelium, which invests the inner surface, consists 
of only one layer and possesses nuclei. The form of the 
nuclei is everywhere the same; they are spherical, sharply 
defined and their contents show many granules. The body 
of the cell however varies very much in regard to shape. 

In the arched, tortuous tubules the epithelium forms a 
connected, gelatinous, cloudy mass, in which nuclei are im- 
bedded at equal distances from each other. A division into 
cells, corresponding to these nuclei seems to be entirely 
absent. 

'•'This epithelial pulp sits very loosely upon the basal 
membrane, " and the whole substance can be easily forced 
out of the cut tubules in the form of a cylindrical mass. 
With the microscope there are discovered many oil globules, 
and also other dark corpuscles which, upon the addition of 
dilute acid are cleared up (cloudy swelling of the epithe- 
lium). After the clearing up with acids it is frequently im- 
possible to distinguish anything distinctly except the nuclei of 
the cells. 



12 EXAMINATION OF THE URINE. 

* * In the narrow tubules, which form the limbs of the loop 
of Henle, there appears, in the place of the dark and bulky 
epithelium, already described, a light and meager epithelium 
which lines the walls of the tubule with a layer that is con- 
siderably arched by the nuclei." 

Beyond the loop of Henle, where the diameter of the tube 
increases, the epithelium looks as if it were made up 
entirely of cylindrical cells, that are arranged like the 
shingles of a house, placed over each other in the direction 
of the medullary to the cortical layer. 

In the intermediate portion the gelatinous layer is again 
found. 

" In the collecting tubules, to the papillary duct, the 
epithelium is made up of cylindrical cells; distinctly separated 
from each othei, that rest with their base upon the tunica 
propria directing their blunted points toward the lumen 
of the tube. 

The Blood vessels of the Kidney. — The renal artery sends 
the greater part of its blood through the cortical portion. 
Its branches penetrate, without forming a net- work, to the 
boundary of the cortex and divide, rapidly, into very 
minute arteries ; the arteriole interlobulares and arteriolae 
rectae. The interlobular arterioles take their course between 
two pyramids of Ferrein where several primitive bundles 
meet. Arrived in the layer of tortuous tubules, they give 
to each Malpighian capsule a branch. This branch (Vas 
afferens glomeruli) perforates the spherical end of the tubule 
(according to other authorities it pushes the same before it), 
and here, terminates "in a pendulous bundle of capillaries, 
(glomeruli), that, in their turn, are collected, within the 
capsule, into one venous branch (Vas afferens glomeruli)." 



THE KIDNEY. 1 3 

This small branch has its exit, from the capsule, at the same 
place that the artery takes its entrance. After it has left the 
capsule, "it first, takes the direction towards its pyramid; or, 
where this is wanting (as in the outer layer of the cortical 
substance), directly toward the tortuous tubules and 
divides into a number of capillaries, that, immediately after 
their origin, combine to form a net-work," and in this way 
produce meshes that surround the uriniferous tubules. All 
the efferent vessels communicate with each other, by means 
of their capillaries, and in this manner form a continuous 
capillary net running through the whole cortical, which, in its 
turn, anastomoses with the meshes around the pyramids, in 
this way being in connexion with the capillaries of the 
medullary portion. 

The arteriolar rectae, all of which enter the medullary part 
from the direction of the cortical "take their course in the 
slit-like spaces, that occur, at the border of the medullary 
part, between the tubules, and strive to reach the papillae ;" 
in that they divide into branches that run in a more parallel 
direction. Where these vessels come into contact with the 
convergent tubules, they divide into capillaries, that sur- 
round these, extending even to the papilla. These capill- 
aries, as has been before mentioned, are connected with 
those of the cortical portion. 

By these capillary nets, the venous trunks are originated. 
In the cortical portion, in that part in which no glomeruli 
are found, the union takes place in the form of stars (Venae 
stellatae.) The common trunk penetrates the cortical por- 
tion which is supplied with tufts and tubules, lies in the 
neighborhood of an interlobular artery, and takes up many 
veins coming from the cortical portion. 



14 EXAMINATION OF THE URINE. 

The veins of the medulla (venulae rectae) run in the 
spaces that are occupied by the arteries, and, at the border 
of the cortex, unite with the veins coming from these to form 
larger trunks. — The capsule of the kidney receives its blood- 
vessels partially, from the interlobular arteries, partially from 
other neighboring trunks (the phrenic, lumbar and supra- 
renal arteries). Their capillaries partly enter the stellate 
veins, partly veins corresponding to the arteries that have 
given the blood. 

The Nerves of the kidney are derived from the coeliac 
plexus of the sympathetic. Their final terminations are not 
known. They follow the course of the larger vessels, as 
well as the lymphatics that enter the lumbar glands. 

II. The Efferent Passages. 

The Ureters, Pelvis of the Kidney and the Calyces are made 
up of an external fibrous membrane, a layer of unstriped 
muscular tissue, and a mucous membrane. The fibrous coat 
is continuous with the albuginea of the kidney and is made 
up of connective tissue and elastic fibres. In the ureters, 
the muscular layer, is distinctly made up of three divisions : 
the inner one runs longitudinally, the middle one transverse- 
ly, and the outer, which is the thinnest, again longitudinally. 
In the pelvis the relations are the same, except in the calyces, 
the muscular layers become thinner and finally disappear 
where they touch the papillae. The mucous membrane is 
thin, rather rich in blood vessels, without glands or papillae. 
The epithelium is present in layers and is characterized by 
the varied form and size of its elements, which, in the deep 
layers, are round and small; in the middle layers, cylindrical 
or spherical with processes; and at the surface rounded, 
many-cornered or, frequently flattened and larger. 



THE BLADDER. 1 5 

The Bladder possesses the same membranes as the ureters. 
The muscular layer is, very often, quite thick ; the indi- 
vidual fibres, however, are distributed so irregularly that 
their schematic course cannot be described. Usually there 
is found, internally a net of circular bundles, that cross each 
other at acute angles, in this way forming meshes that lie trans- 
versely. These circular fibres are thickest at the opening 
of the bladder and here form the sphincters of the bladder. 
Upon these circular bundles follow longitudinal fibres, which 
in their turn have a very inconstant distribution. The trigon- 
um consists simply of a thickening of the connective tissue 
layer, extending from the opening of the ureter to the caput 
gallinaginis. The mucous membrane (except at the trigonum) 
has a thick sub-mucous layer; this is rich in blood vessels and 
nerves (especially at the neck and fundus of the bladder). 

In the neck of the bladder and towards the fundus are 
found simple racemose glands, which have cylindrical epithe- 
lium and mucous contents. 

In the bladder is found epithelium that is arranged in 
several layers and, like that of the ureter differs in the differ- 
ent layers. Innermost are found cells, that have a more 
flattened form, but varying very much in respect to form and 
size. The middle layer, is usually composed of young, con- 
ical cells, presenting their apices toward the cavity of the 
bladder, whose processes can be frequently traced into 
the deeper layer. The outer layer is composed of ovoid 
cells irregular, and frequently where in contact with the mid- 
dle layer, drawn out. 

The superior and inferior vesical arteries, branches of the 
hypogastric, supply the bladder with blood; these enter the 
wall of the bladder at the fundus, pass through the muscular 



l6 EXAMINATION OF THE URINE. 

coat, obliquely, giving off branches to the same ; and then 
divide into capillaries in the connective tissue under the 
epithelium. In the connective tissue at the fundus, where 
they are not numerous, the nerve fibres can still be distin- 
guished as possessing white substance of Schwann. Their 
terminal branches are not known. The vessels and nerves 
of the ureter are analogous to those of the bladder. 

The Male Uretha has a corpus cavernosum whose struc- 
ture is like that of the penis, fibrous membrane and meshes, 
only much more delicate ; and a glandular organ — the 
prostate gland, which forms its support. Under the mucous 
membrane, throughout its whole extent and below it, there is 
a well developed connective tissue layer, rich in elastic fibres; 
there are to be found also organic muscular fibres, arranged 
both longitudinally and transversely. 

The epithelium of the male urethra is cylindrical and 
arranged in layers ; with the exception of the exterior part of 
the fossa navicularis where papillae, and flat epithelium are 
already to be found. The cells of the accessory glands, those 
of the prostate, Cowper's and Littre's glands, and of the 
vesicula prostatica are conical and can hardly be distin- 
guished from those of the urethra. 

The Female Uretha has no corpus cavernosum ; the mucous 
membrane is rich in vascular supply, and has flat epithelium 
in layers. In addition there are very few glands of Littre to 
be found in it. 



EXCRETION OF URINE. 1 7 



CHAPTER II. 

Excretion of the Urine. 

The function of the kidney is to excrete the urine; that of 
the bladder and ureters, on the other hand, to collect, retain 
and carry it off. A theory which is entirely satisfactory, and 
explains all facts, concerning the excretion of urine does not, 
as yet, exist. 

Bowman, relying upon the anatomical structure of the 
kidney, thinks that the epithelial cells are secretory organs, 
and that water only, is excreted by the tufts, which washes 
the constituents of urine out of the epithelial cells. Ludwig 
bases his theory, on the one hand, upon the different amount 
of blood pressure in the various blood vessels of the kidney; 
on the other hand, upon the different capacity that sub- 
stances possess of passing through animal membranes. He 
assumes, that the pressure upon the glomeruli is greater than 
in the capillaries surrounding the uriniferous tubules. As a 
result, an abundant transudation of water, and salts in solu- 
tion (serum of blood, little albumen and fat) must take 
place from the blood into the Malpighian capsule. In this 
way there is to be found in the uriniferous tubules, a very 
dilute urine and in the capillaries surrounding the tubule, 
blood that is very much concentrated. 

These two fluids, differing so widely in density, and separ- 
ated from each other by animal membrane, produce active 
currents of diffusion, as a result of which, water is added to 
3 



1 8 EXAMINATION OF THE URINE. 

the concentrated blood, on the one side ; and on the other, 
products of retrograde metamorphosis (urea) and salts are 
added to the dilute urine in the uriniferous tubules. In this 
way the watery urine becomes more concentrated, richer in 
urea and salts; becomes urine. The absence of albumen is to 
be explained, in that this substance does not easily pass 
through animal membranes, and then only as a result of in- 
creased pressure (the walls of the blood vessels and tubules 
are animal membrane): accompanying pathological conditions, 
with increased pressure in the glomeruli (stasis in the veins 
of the kidney) albumen is always found in the urine, but 
under normal pressure this is never the case. Although this 
theory explains many physiological and pathological facts, 
yet it does not explain how an alkaline serum of the blood 
produces an acid urine. According to this mechanical 
theory of Ludwig the excretion of urine is a process of filtra- 
tion taking place in the glomerulus and a process of diffusion 
throughout the course of the tubules; the epithelial cells 
lining the tubules are not taken into consideration at all. 

According to Goll and Max Hermann, the difference in 
pressure between the contents of the vessels and urinary 
tubules, is the principal force that causes the transmission of 
the constituents of the urine from the blood to the tubules. 
According to this, when pressure is increased in the renal 
artery, the quantity of urine also increases; but when the 
pressure in the artery is diminished, or when, pressure in 
the ureters is increased, blood pressure remaining normal 
in the ureter, the excretion diminishes and, can even stop 
entirely, long before the pressure in the ureters equals that in 
the renal artery. 

Ustimowitsch and Grlitzner, have elaborated this theory, 



EXCRETION OF URINE. 1 9 

in so far, that they showed, by means of experiments on 
dogs, that only the local pressure in the glomeruli, not the 
general blood pressure must be taken into consideration. 

Upon section of the medulla in the dog, and electric irri- 
tation of the same, producing increased blood pressure, 
excretion of urine ceased entirely, because, the smaller ves- 
sels of the kidney contracted. If the nerves on one side 
going to the kidney were divided, there would follow, upon 
this side, a profuse flow of urine, whilst, upon the other, 
no urine would flow from the ureter. By means of di- 
vision of the nerves going to the kidneys, its smallest 
arteries become dilated and relaxed, in this way increasing 
pressure in the smaller vessels and stimulating the flow of 
urine. 

In addition, Ustimowitsch demonstrated that an increase 
in excretion of urine can take place even when the general 
blood pressure is diminished. If. the splanchnic nerve be 
divided, which contains the vasomotoric tracts for the kidney, 
the pressure in the aorta is diminished — at the same time, 
however, dilatation of the smaller arteries in the kidney en- 
sues so that an increase in excretion can be verified. 

Heidenhein and Wittich support the views of Bowman, in 
that they show that in their experiments with indigo-sulphate 
of sodium, urate of sodium and carminate of ammonium 
these substances are secreted principally by the epithelium 
of the tortuous tubules. 

According to the experiments of K. Mliller, the quantity 
of urine is increased by the action of cold upon the skin ; 
warm baths, on the other hand, or varnishing the surface of 
the body, the latter producing dilation of the blood vessels in 
the skin, cause a diminution in the urine. 



20 EXAMINATION OF THE URINE. 

An increase in the circulation of the skin, then increases, 
a diminution of the same diminishes the excretion of urine. 

According to Wendt, the addition of intra-abdominal press- 
ure impedes the excretion of urine. Possibly pressure in the 
veins increases, which, as is known (Ludwig) diminishes the 
quantity of urine. 

Maly, Donath, and Posch state that by osmosis, a solu- 
tion that is made up of several different salts (for instance 
mono and disodic phosphate) which together possess a 
neutral or even alkaline reaction, may result in one having an 
acid reaction. This is exceedingly important because the 
necessity of ascribing to the epithelial cells the property of 
causing the formation of acid is entirely unnecessary. 

Notwithstanding all the explanations, all hypotheses are 
not completely satisfactory when all physiological and chem- 
ical processes in excretion of urine are taken into consider- 
tion We must, therefore, still look upon this process as a 
combination of secretion and filtration. 



THE URINE. 21 



CHAPTER III. 

THE URINE. 
A. — In General. 

Urine is the secretion of the kidney, and in the normal 
condition represents a solution of those substances that 
pertain to retrograde metamorphosis. It is a solution of 
urea and common salt, to which are added, in small quan- 
tities, other organic and inorganic constitutents of the blood, 
also, certain substances introduced into the system which are 
excreted either in their unchanged condition or after having 
undergone a chemical decomposition. 

In the normal condition the urine contains organic 
constituents (urea, uric acid, creatinine, hippuric acid, xan- 
thine, lactic acid, grape sugar, etc., Brlicke); inorganic 
constituents (chloride of sodium, phosphate of sodium, 
calcium and magnesium, sulphates of the alkalis, salts 
of ammonium and iron, in combination with the coloring 
matter and gases, carbonic oxide, nitrogen and oxygen). 

In pathological urine there can be detected, in addition to 
these normal substances, albumen, grape sugar, inosit, con- 
stituents of bile, fats, sulphide of hydrogen, blood coloring 
matter, uorerythrine (Heller), leucine and tyrosine, calcic car- 
bonate and oxalate, carbonate of ammonium, cystine, pus, 
blood, epithelial structures, spermatozoa, fungi and infusoria. 

Before considering the symptomatological value of urine, 
we must look at its properties (as far as they interest us) and 
the most valuable methods for its examination. 



22 EXAMINATION OF THE URINE. 

B. — Physical Properties. 
I. Quantity. 

The quantity of urine that is voided by a healthy man that 
eats and drinks moderately, in twenty-four hours, varies 
from i .400-1 .600 c. c.; average, 1.500 c. c. 

The greatest quantity is secreted during the afternoon, 
the smallest during the night; the mean occurs in the morn- 
ing, and at this time the urine represents, in every respect, 
an average, being least influenced by meals. 

By means of the introduction of fluid into the system the 
quantity of urine can be enormously increased (urina potus); 
an increase, less marked, can be noticed during very cold or 
moist weather (less perspiration). During rest or great pers- 
piration and profuse diarrhoea the quantity is diminished. 

II. Specific Gravity. 

The Specific Gravity of a normal urine of 1.500 c. c. 
quantity is from 1.015 to 1.021. If the quantity increases 
or diminishes the specific gravity changes in inverse ratio. 
In pathological cases the specific gravity varies from 1.003 to 
1.040. Those cases are of special importance, in which 
with small volume there is low specific gravity, or with 
great volume high specific gravity. A high specific gravity 
is found frequently in diabetes mellitus, in the beginning of 
acute diseases and during the administration of salts. Urine 
of great quantity, having a specific gravity of between 1.003 
and 1.040 is always very suspicious as indicating diabetes 
mellitus. A low specific gravity is observed in hydruria, 
urina spastica and urina potus. 



THE URINE 23 

Specific gravity can be accurately determined either by 
means of the picnometer or the scales of Westphal. For 
practical purposes, however, small areometers (called urin- 
ometers) are employed. 

If the specific gravity is to be determined by means of 
the urinometer, a suitable vessel is filled four-fifths full, all 
air-bubbles are removed with filtering paper, and the urin- 
ometer then introduced in that, it is allowed to slide between 
the index and middle finger of the right hand. The urin- 
ometer must not be allowed to touch the walls of the vessel. 
Bring the eye on the same plane with the surface of the 
fluid, and read from that division of the scale that corres- 
ponds with the surface of the urine (not with that surface 
that is drawn up on the scale by means of attraction). 
[Note. — A simple rule is to read from the lowest level of 
the fluid; in this way both attraction of the walls of the 
vessel, and also of the stem of the urinometer, are disre- 
garded]. Then the urinometer is immersed into the fluid 
and again read. 

In taking specific gravity with the urinometer, the tem- 
perature must be between 12-17 C, otherwise a great error 
can be made. 

If the quantity of urine for observation be very small, it 
is to be diluted with two, three or four times its volume of 
water, the urinometer is then introduced, and the result is 
multiplied by the diluted volumes. Thus, if one volume of 
urine has been diluted with three volumes of water, and the 
areometer marks 1.008, the real specific gravity is obtained 
from this apparent specific gravity by multiplying ,the last 
two figures of 1.008 by 14-3=4 : 

1.008X4=1-032. 



24 EXAMINATION OF THE URINE. 

The same quantity of solids that was dissolved in one vol- 
ume is now dissolved in four; the specific gravity after di- 
lution is, therefore, only one-fourth of the real, or the real 
specific gravity is four times that of the dilute. 



III. Solids. 

The quantity of solids secreted in the urine in twenty-four 
hours varies between 60 and 70 grammes. If a greater 
amount, than 200.00 gr. is found, we have to deal with dia- 
betes. If, on the other hand, the quantity being nearly nor- 
mal, we find only 20.00 grammes, we have hydruria. In 
order to determine, approximately, the quantity of solids 
present in 24 hours, either Trapp's (2) or Haeser's (2.33) 
coefficient can be employed. (For accurate determination 
see Chapter V.) First, the specific gravity of the urine is 
found. If the last two figures are multiplied by the coef- 
ficient, the answer will be the quantity of solid constituents 
found in 1000 c. c. (in grammes.) If the quantity of urine 
is known, we can easily determine from this how much 
there is found in 24 hours. For instance, we have a 
urine of 1500 c. c. in quantity during 24 hours, its specific 
gravity is 1.020; in order to find the amount of solids in 
1000 c. c. the last two figures, 20, are multiplied by Haeser's 
coefficient 2.33 : 

20X2.33=46.60. 

This product represents the amount of solids, in grammes, 
in 1,000 c. c. of urine; from this we can readily establish 
the proportion : 

1,000:46.60:: i50o:x, 



PHYSICAL PROPERTIES. 25 

and in solving it find the quantity in 24 hours. In this in- 
sance, x=69.(po — nearly the normal quantity. 

In the following, the quantity of solids in 24 hours of dif- 
ferent urine will be given: 

Ex. I. — Quantity, 4,000, c. c. 
Sp. gr. 1.007. 

o7X2.33 ==l6 -3 I - 
1,000 c. c. urine, therefore, contain 16.31 gr. solids — 4,000 c. c.=65.24 
gr. From this we see that the quantity of solids is normal, that the 
water alone is increased. 

Ex. II. — Quantity, 6,000 c. c. 
Sp.gr. 1. 01 3. 

I 3X2.33=3°- 2 9- 
In 1,000 c. c. urine we have 30.29 gr. solids in 6,000 c. c: 

1,000:6,000: : 30.29:^ 

^•=iSi.74gr. 
In this urine the solids in 24 hours are more than double the normal 
quantity, we having here a case corresponding to diabetes. 

Ex. III. — Quantity, 2,000 c. c. 
Sp. gr. 1.005. 
05X2.32=11.65 gr. 
1,000 c. c. contain 11.65 — 2,000=23.30 gr. The solid constituents 
are very much diminished — an hydruria. 

The differential diagnosis between diabetes, insipidus and 
hydruria on the one hand, and urina potus on the other; as 
also between oligenia and normal urine, can be made sim- 
ply by taking the solid constituents of the 24 hours into 
consideration. 

Other important deductions can be drawn from the quan- 
tity of solids and the specific gravity, the observer being 
guided by the individual case under observation. Thus, a 
4 



26 EXAMINATION OF THE URINE. 

disease of the kidney has been demonstrated ; the quantity 
of urine being normal or diminished, and the specific grav- 
ity very low, the deduction can be drawn that as urea rep- 
resents nearly one-half the solids; this substance is not ex- 
creted in sufficient quantity, uraemia may be imminent, etc. 

As the ratio of the solids in solution is not constant, the 
calculation from the specific gravity cannot be accurate. An 
error of 6% can be made (in abnormal urine even more), 
/. e. having computed in 1,000 parts 50 gr., of solids, and 
finding only 47 or 53 gr., on the next day we cannot say 
that the solids have increased or diminished. 

In judging the changes in the body by the specific grav- 
ity, we must, in addition, take into consideration whether or 
not the usual amount of food is taken up, or (as in acute 
diseases) whether the patient abstains from food. In the 
latter instance, an average of 30.00 gr. must be taken, so 
that a patient passing 40.00 gr., having pneumonia and ab- 
staining from food, really passes more than the normal quan- 
tity — an increase that takes place at the cost of the body. 

IV. Consistency. 

The consistency of normal urine is that of a thin fluid 
that can be easily separated into drops. Under pathologi- 
cal conditions the urine becomes thick. When a great 
amount of pus is present in alkaline urine, the urine can be 
drawn out like the contents of a cyst containing paralbu- 
mine. Diluted with water and precipitated with acetic acid, 
a dense cloudiness arises, which is an alkaline albuminate, 
formed by the action of the alkaline urine on pus. 

In Isle de France, it is stated that urine is observed that 
coagulates in the vessel like lymph, and contains fibrine 



PHYSICAL PROPERTIES. 27 

(fibrinuria). In our zone this form of urine is exceedingly- 
rare. In several cases of papillary tumors of the bladder 
we have observed temporary fibrinuria. 

The urine that was fluid at the time it was voided, red- 
dish-yellow and containing very little blood, in a few min- 
utes was changed to a trembling, gelatinous mass, that could 
no longer be poured from the vessel that contained it. 

Upon shaking normal urine a foam is formed which disap- 
pears in a very short time when the vessel is put down ; if 
the urine contains sugar or albumen the foam will remain 
for some time. (Bile also gives to urine a certain amount of 
tenacity, so that bubbles are retained upon the surface for 
some time.) 

V. Color. 

The normal color of urine of 1.020 sp. gr. and 1500 c. c 
quantity in 24 hours, is wine-yellow. In concentrated urine 
it varies from dark wine-yellow to that of amber; in diluted, 
from pale wine-yellow to straw-colored. The urine passed 
in the morning ; or when people have perspired, always has a 
dark, and urina potus a light color. In addition, in patho- 
logical conditions, the urine undergoes much greater changes, 
for which, very commonly, abnormal coloring matter must 
be looked upon as the cause. 

Urine can be divided into the following varieties, in re- 
spect to color : 

1. Nearly Colorless. — Especially in neuroses do we meet 
with a " urina spastica," which can hardly be distinguished 
from water. In other varieties of hydruria and diabetes, 
the coloring may be very faint, although the yellow is un- 
mistakable. A change, however, can set in in the course of 
a few hours, so that then a darker urine is passed. 



28 EXAMINATION OF THE URINE. 

Light urine arises from the presence of the normal quan. 
tity of coloring matter in much water (urina potus, urina 
spastica) or normal amount of water and diminished color- 
ing matter (as in the granular kidney) ; in most cases both 
factors are present. 

2. Highly Colored. — Dark yellow, somewhat reddish, to 
red. This color is not only produced by concentration, but 
frequently by the presence of uroerythrine. It is met with 
in fever, in the stages of increase and acme. 

3. Blood Red to Garnet is always produced by the presence 
of some foreign coloring matter. Numerous substances 
from the vegetable kingdom, when excreted by the kidneys, 
impart to alkaline urine a red color. The same occurs when 
blood is found in the urine 

4. Dark Brown to Black is caused by the presence of 
methsemoglobine in diseases of the kidney, especially 
hemorrhages, by the presence of biliary coloring matter in 
the urine (icteric urine-jaundice) and by coloring matter 
that is not definitely known to us, as in long-continued at- 
tacks of intermittent fever. 

Sometimes in melanotic cancers, after the urine has been 
allowed to stand for some time, it becomes black. As this 
form of coloring matter has been found without the pres- 
ence of a cancer and vice versa, not much symptomatic reli- 
ance can be placed upon its presence or absence. After the 
external use of carbolic acid (according to Lister's method) 
very dark urine is also observed, but this is not constant. 

Occasionally in the urine of children, a brownish discol- 
oration going from the surface to the bottom is observed, due 
to the presence of pyrocatechine. In lepra we see the dark 
red urine changed to a dark brown, as the fatal end 
approaches (urorubrohematine). 



PHYSICAL PROPERTIES. 29 

5. Green, of a dirty shade, is produced in jaundice, by 
the presence of biliverdine, and is of the same importance 
as brown, icteric urine. 

6. Bluish, that produces a dark blue film and a similar 
precipitate of indican. The urine always is alkaline — most 
frequently met with in cholera and typhus. 

VI. Transparency and Fluorescence. 

Normal urine is always clear and transparent, and only 
when it has stood for a long time can we distinguish a small 
cloudiness of mucus (nubecula). With the microscope, there 
are found in this, epethelial cells, flat and round. 

The nubecula, in females, is usually more abundant and 
more epithelium is found in it, especially in layers, coming 
from the genitals. Pathologically the urine becomes cloudy 
from all those substances that are found in the sediment. 

If we want to detect the chemical nature of the turbid- 
ity, the following method is employed : A test-tube is 
filled one-third full with the urine that we wish to examine, 
and carefully heated over a lamp. 

(a) If the cloudiness disappears entirely, urates which 
are beginning to be precipitated are suspended. 

(ft) If the cloudiness does not disappear, but, rather, 
seems to increase, it may depend on carbonate of calcium, 
the earthy phosphates, or albuminous cellular elements (pus, 
blood). In order to differentiate, a few drops of acetic acid 
are added. If the urine clears up, the earthy phosphates 
have caused the turbidity ; if this is not the case, or if the 
turbidity increases, suspended pus or blood can in most 
cases be considered the cause. 



30 EXAMINATION OF THE URINE. 

(c) If the urine does not undergo any change when 
heated, and a slight increase in cloudiness, only, be de- 
tected, a greater amount of mucus and bacteria, than nor- 
mal, can be deduced. 

Normal urine sometimes is markedly fluorescent ; as yet 
we are unable to state the substances that produce it. Al- 
kaline urine, by reflected light, appears greenish ; by trans- 
mitted, yellowish red. Some urine shows the spectrum of 
urobiline. 

VII. Odor. 

The odor of fresh human urine is faintly aromatic. The 
substances causing this are unknown. If the urine has un- 
dergone alkaline fermentation, a distinct ammoniacal odor is 
perceptible. In destructive processes in the bladder, a pe- 
culiar, fetid, sometimes fecal smell is present. Upon the 
introduction of certain articles of food, or the taking of cer- 
tain drugs, the odor of the urine is changed in a marked 
manner; for instance, after eating asparagus, cauliflower, 
etc. After turpentine, the odor is like that of violets. The 
odoriferous principles of cubebs, saffron, etc., can also be 
detected in the urine. 

VIII. Reaction. 

Normal urine has an acid reaction ; this depends princi- 
pally upon the acid phosphate of the alkalies. 

It may be produced, also, by free organic acids (lactic ?) 
At all events the role that is played by these acids in pro- 
ducing the reaction is secondary. If to a fluid, containing 
free acid, a solution of sodic hyposulphite be added, it be- 
comes turbid on account of the precipitation of sulphur. 



PHYSICAL PROPERTIES. 3 I 

If this experiment be tried with urine, even after 24 hours 
a very slight, sometimes no, turbidity sets in; therefore, 
(even if we do not consider this test as absolute), the amount 
of free acid in the urine cannot be very great. Sometimes, 
after a meal, alkaline urine is voided ; this, however, disap- 
pears in a short time, and is of no clinical importance. 

Great acidity of the urine is important to the physician, 
in that it may favor the development of sediments or con- 
cretions, and may give rise to irritation of the kidneys and 
the urinary passages (Vogel). 

Acid reaction may be changed to neutral or even alka- 
line. The use of the carbonates of the alkalies and earths, 
or organic salts (acetates, pomates, tartrates,) which change 
to carbonates in the organism, may cause the urine to be- 
come alkaline. The urine may also be alkaline from car- 
bonate of ammonia, that has been formed by urea taking up 
water. 

At first, the quantity of ammonium-corbonate is only suf- 
ficient to neutralize the urine; therefore, the neutral reaction 
is of the same value as the alkaline. 

An urine of strong alkaline reaction always points to dis- 
ease of the bladder, provided excretion of alkalies by the 
urine has been excluded. 

The test is, usually, very delicate bluish violet and faintly 
red litmus paper. 

We must discriminate between the change to the alkaline 
taking place before or after the urine leaves the bladder. 
Furthermore, whether the alkalinity depends upon ammo- 
nium carbonate (splitting up of urea), or fixed carbonate 
(absorption). This can be done by allowing the litmus paper 
to lie in a warm place until it becomes dry; if ammonium 



32 EXAMINATION OF THE URINE 

has produced the change, the red color reappears; if this 
does not take place, the alkalies present are fixed. 

Occasionally urine is observed that turns blue litmus red, 
and red, blue. This reaction is known as the amphoteric, has 
found no explanation, and has no symptomatic importance. 

CHEMICAL COMPOSITION. 

(a) NORMAL ORGANIC CONSTITUENTS. 

We preface the discussion of the individual substances by 
a table representing the average quantity excreted. In 24 
hours there are voided : 

Grammes. Per cent. 

Solids 60 — 70 4.3 — 4.6 

Urea 30 — 40 2.5 — 3.2 

Uric Acid 0.4 — 0.8 0.03 — 0.05 

Creatinine o. 5 — 1 .0 o. 03 6 — 0.06 2 

Hippuric Acid 0.3 — 1 .0 0.02 — o. 06 

Chlorides 10 — 13 0.7 — 0.8 

Earthy Phosphates 0.9 — 1.3 0.07 — 0.08 

Phosphoric Acid 2.5 — 3.5 0.19 — 0.22 

Sulphuric Acid 1.5 — 2.5 0.16 — 0.17 

From this we see that the greatest amounts are repre- 
sented by urea and the chlorides. From this it is easily un- 
derstood how, when one of these substances is absent in 
urine, a decided effect is produced upon specific gravity. 

This does not hold good, equally, for the other normal 
constituents, as they are excreted relatively in very small 
quantities. 

The amount of gases is practically unimportant. Car- 
bonic acid gas is present in greatest amount (60 — 150 c. c. 
in 1,000 c. c. urine). Nitrogen is present in very small 
amount, and of oxygen traces only can be discovered. 



CHEMICAL COMPOSITION. 33 

I. Urea. 

Urea CH 4 N 2 0, is the most constant constituent and the 
one that occurs in greatest amount. In 24 hours a healthy- 
adult will excrete between thirty and forty grammes of urea. 

Animal diet produces greater quantities of urea than 
mixed, and the latter more than vegetable food, exclusively. 
In inanition the quantity falls to twenty, even fifteen 
grammes. The latter figures must be taken into considera- 
tion if we wish to form an idea of the changes in the econ- 
omy of patients put upon absolute diet. 

Urea is obtained from the urine in the simplest manner, as follows : 

After precipitating the inorganic salts with the barium solution used 

in the volumetric urea test, evaporate to dryness, extract with alcohol, 

filter, then evaporate the alcohol; finally recrystallize the crystals 

with absolute alcohol. Another method consists in concentrating 

urine to the consistency of a thin syrup, then adding pure nitric 

acid (cold), as a result of which nitrate of urea is precipitated. 

These crystals are decomposed with carbonate of barium, and then 

drying, the urea is extracted by alcohol. Synthetically urea can be 

made from ammonium cyanate; 80 parts of ferro-cyanide of potassium 

are melted with 30 parts of carbonate of potassium in a crucible. 

By means of 150 parts of litharge the cyanide of potassium 

that has been formed (CNK) is changed to the cyanate CNOK. This 

is then poured upon an iron plate. After it has cooled it is dissolved 

in a solution of 80 parts of sulphate of ammonium ((NHJ 2 S0 4 ) in 

500 parts of water ; a double decomposition takes place, producing 

CN, O.H 4 N cyanate of ammonium and K 2 S0 4 (potassic sulphate), 

then filter and dry. Whilst evaporating, the transposition of atoms 

takes place, so that from the cyanate of ammonium we obtain urea — 

as follows : 

CN _ CQ NH 2 

(Cyanate of ammonium.) (Urea.) 

The dried mass is extracted with alcohol, and allowed to crystallize. 

5 



34 



EXAMINATION OF THE URINE. 




Urea crystallizes in the form of glistening, white needles 
(under the microscope); when viewed with the naked eye, 
in long, transparent F*g-3. 

quadrilateral prisms, 
whose ends are ter-l 
minated by one or two 
slanting planes. It is 
easily soluble in water | 
and alcohol, but insolu- 
ble in ether. Heated, | 
moderately, on plati- 
num, it melts and de- 
velops ammonia. 
Mixed with putrescent I 
urine, or the secretion [ 
from cystitis, it is sepa- 
rated in the Opposite a, Crystals of urea; b, crystals of nitrate of urea. 

way from its formation. It splits up into i molecule of car- 
bonic acid gas and 2 molecules of ammonia, taking up 1 
molecule of water (CH 4 N 2 0+H 2 0=C0 2 +2H 3 N). 

This same decomposition takes place when boiled with 
strong mineral acids, melted with caustic alkalies, or when 
heated with caustic barium in a sealed tube. When nitrous 
acid, hypochlorite or hypobromite of sodium are added, urea 
is split up into carbonic acid, water and nitrogen. 

Urea is carbamide. For details see K. B. Hofman's Zoochem- 
istry — in English — Fowne's Elementary, or Kingzett's Animal Chem- 
istry. 

Nitrate of mercury, with solutions of urea, produces a 
flaky white precipitate, equalling 2, 3, or 4 equivalents of 
mercury to 1 of urea, according to the concentration of the 
fluid. With common salt, also, urea enters into combi- 
nation. 



CHEMICAL COMPOSITION. 



35 



When nitric acid is added to concentrated urine, or to a 
concentrated solution of urea, beautiful rhombic plates are 
formed, which may frequently be seen with the naked eye. 

If one has only a drop of fluid which must be tested for 
urea, this is put upon a slide; a drop of nitric acid is ad- 
ded; this is gently heated over a spirit lamp, then put aside 
to crystallize. Under the microscope there are observed. 
either single rhombic or hexagonal plates, or these are seen 
in great number, more or less developed, lying upon each 
other like shingles, and in rows, generally, intersecting each 
other at right angles. The acute angle of the rhombus is 
82°. This test is most frequently resorted to on account of 
the facility with which it is carried out, and also on account 
of the characteristic form of the crystal of nitrate of urea. 

In albuminuria the nitrate of urea takes another form, 
that of brush-shape needles. (Hoffman. 1. c.) 

A concentrated solution of urea, decomposed by oxalic 
acid produces crystals that look like those of nitrate of urea; 
but as this form does not appear so regularly as the former, 
this reaction is looked upon more as corroborating and ver- 
ifying, having been preceded by the nitric acid test. 

These reactions can all be carried out with concentrated 
urine, but when albumen is present, this must first be gotten 
rid of, by means of coagulation. 

If the question comes up whether a fluid is urine, the 
first thins: to be decided would be the determination of the 
presence of urea and uric acid. If a few drops only were 
presented, the micro-chemical reaction for urea would be 
decisive. We must not forget, however, that some transuda- 
tions contain urea. 

As urea, of all the constituents of urine, is present in 



36 EXAMINATION OF THE URINE. 

greatest quantity, we can deduct from the specific gravity, 
approximately, the quantity of urea, provided no sugar and 
no great amount of albumen can be detected, and provided 
the chlorides be present in normal quantity. This being 
the case, and a urine whose specific gravity is between 1020 
and 1024, we can state that such an urine contains a normal 
percentage of urea, /. e., between 2 and 2.5 °/ . If, under 
the same conditions, we find increased or diminished spe- 
cific gravity, we can state that the percentage of urea is, 
correspondingly, increased or diminished. If the specific 
gravity is ioi4the urine contains about 1 % urea; if 1028- 
1030, it contains 3 ^ urea. 

If the chlorides are present only in small quantity or can 
not be detected at all, as occasionally happens in acute feb- 
rile diseases, even with normal specific gravity, then the 
percentage of urea is increased; for the 16 grammes of 
chlorides that are present in normal urine, and which is the 
second greatest factor in influencing specific gravity (always 
excluding sugar and albumen), are absent in this case, there- 
fore the specific gravity of 1020 must be produced by the 
urea; for all the remaining constituents of urine, uric acid, 
creatinine, the phosphates and sulphates, if they were in- 
creased to even double their normal quantity, could have 
very little influence upon the specific gravity. 

If albumen be present in moderate quantity (0.2%), 
which can be detected by means of the nitric acid test, pro- 
ducing a translucent layer of precipitate, it has very little 
influence upon the specific gravity, and can be neglected en- 
tirely in the approximation of urea. But if albumen be 
present in greater quantity (1-2 %), then it must be re- 



CHEMICAL COMPOSITION. 37 

moved by coagulation and the filtered urine must be exam- 
ined after it has cooled off. 

For this purpose it is best to take a given quantity of urine, 
for instance 50 c. c, heat it in a flask, after having added a 
few drops of acetic acid, to the boiling point ; allow it to 
cool, then filter and wash the filtering paper with distilled 
water until the fluid that has been lost by evaporation is 
made up. Thereupon the specific gravity of this urine that 
has been deprived of albumen is determined. 

Usually urine containing albumen is of itself of a lighter 
specific gravity than the normal urine on account of the dis- 
ease of the urine-producing organs preventing the secretion 
from containing that quantity of excreted matter (especially 
urea) that is found when the kidney functionates normally. 
As a result, the specific gravity must become less. The 
quantity of albumen is rarely sufficiently great to substitute 
the urea in regard to the specific gravity. 

When sugar is present in large quantity, then the per 
cent, of urea is always diminished, although the entire quan- 
tity of urea excreted is always increased. The high specific 
gravity depends upon the sugar. 

Although we have never succeeded in obtaining urea from 
proteme, artificially, notwithstanding many statements to the 
contrary, yet this must be considered as its only source. 
Urea is not the only, but the most important, measure of 
tissue change. It owes its origin partly to the retrograde 
metamorphosis of tissue (including the blood), partly to the 
decomposition of superfluous nitrogenous food. Whether 
urea originates in gradual oxidation ; whether its molecule 
is separated from one more complex, by means of fermenta- 
tion; whether this separation takes place from the albumen- 



38 EXAMINATION OF THE URINE. 

molecule directly, or from a gradual division of this mole- 
cule into smaller ones (intermediate molecules), from which, 
by oxidation, urea is generated, is, as yet, undecided. It is 
proven that certain combinations that are found in the body, 
belonging to the uric acid group (uric acid, allantoine, crea- 
tine, sarcine, xanthine, guanine), and certain derivates of 
prote'ine (glycocoll, leucine, aspartic acid), when introduced 
in considerable quantities into the body will produce an in- 
crease in urea. 

An increase of the urea, to such an extent that upon the 
addition of nitric acid a pulp of nitrate of urea is formed is 
found : 

1. When the diet is principally animal. 

2. In acute febrile diseases, until the acme is reached. 
Urea in this case comes from increased wear of the nitroge- 
nous elements. 

3. In diabetes mellitus and insipidus. 
Urea is diminished : 

1. When the diet is vegetable and in fasting. 

2. In chronic diseases where tissue change is impaired 
(cachexias). 

3. In parenchymatous affections of the kidney, accom- 
panied by uraemia, especially before death (7 gr.!) 

The percentage of urea is diminished in urina potus, spas- 
tica and diabetes, but if the quantity in 24 hours be taken 
into consideration, it will be found that the urea is usually 
increased, at least it is present in normal quantity. 
II. Uric Acid. 
C 5 NH 4 3 
Uric acid is always found in the urine of carnivora. The 
healthy adult usually voids from 0.4 — 0.8 grammes in 24 
hours. 



CHEMICAL COMPOSITION. 39 

It is sparingly soluble in (14,000 parts of cold and 1,800 of 
warm) water, and entirely insoluble in alcohol and ether. 
This alone speaks for the fact, that uric acid is not present 
free in the urine, but nearly all of it in the form of the urates. 

In a warm solution of normal alkali phosphate, uric acid 
is much more soluble than in water, because it withdraws 
from the phosphate part of its base. In this way, then, is 
produced an acid alkali phosphate and an alkali urate. 

Free uric acid, as well as its salts, always appears colored 
in the sediment, the intensity depending on the color of the 
urine. 

In order to obtain uric acid from urine, 20 parts of the latter are 
mixed with 1 part of hydrochloric acid, and the whole allowed to 
stand for 24 honrs. A crystalline powder or membrane is separated, 
consisting of uric acid, on the bottom and walls of the vessel, and 
also on the surface of the fluid. 

The primary crystal of uric acid is the whetstone, or, 
better, a rhombic vertical prism. In this form, and varia- 
tions we find it; also in native sediments. If uric acid is 
separated from urine by means of hydrochloric acid, the 
forms are somewhat changed. They seem coarser and 
more highly colored. Usually there are found under the 
microscope double whetstones, in the form of a cross; groups 
of narrow and long whetstones arranged parallel to each 
other, or like needles, which resemble, somewhat, a comb, 
having teeth on both sides. It is rare to find single crystals. 
If the uric acid that has been precipitated by hydrochloric 
acid, is separated by filtration, redissolved in potassium or 
sodium hydrate, and reprecipitated by hydrochloric acid, 
the result will be a much whiter deposit. Repeating the 
process, frequently, will finally produce snowy white crys- 
tals, even from human urine. Uric acid can also be puri- 



40 EXAMINATION OF THE URINE. 

fied by means of dissolving in sulphuric acid and then pre- 
cipitating by adding a great quantity of water. 

In fresh urine, uric acid or the urates ought never to be 
found; if this occurs frequently, our attention must be 
drawn to the formation of calculi. 

In the formation of gravel and calculi it occurs that con- 
crements of uric acid are passed that are too large for micro- 
scopic examination, and, therefore, do not permit of an 
accurate diagnosis regarding their structure. In these cases 
the chemical test, murexide, will give us positive results. 

To make this test the concrement is pulverized in a small 
mortar, put into a porcelain evaporating dish, and then a few 
drops of nitric acid and a small quantity of water are added. 
This is heated until the uric acid has dissolved, and then the 
fluids are driven off. Whilst evaporating, if uric acid be pres- 
ent, we notice on the walls of the vessel intense red deposits 
that disappear as soon as we approach them with the lamp. 
When the solution has been nearly evaporated to dryness, 
and a drop of aqua ammonia is added, the whole contents 
of the dish appear of a beautiful purple (murexide-purpur- 
ate of ammonium) ; then add a drop of a solution of hy- 
drated potassium, and the solution appears violet. This 
reaction depends upon a change in the uric acid to alloxan 
and alloxantine, which by the ammonium are converted into 
murexide. 

Instead of using the test, the concrement may be dis- 
solved in potassium hydrate, precipitated by hydrochloric 
acid and examined under the microscope, the crystals being 
characteristic for uric acid. 

If only small quantities of suspected fluid are at 
our disposal, they are put into a watch glass, together with a 



URIC ACID. 41 

linen thread, 6-8 drops of glacial acetic acid are added ; the 
whole is allowed to stand for 24 hours at i5°C. 

Adding to an alkaline solution of uric acid a diluted so- 
lution of cupric sulphate will produce a white precipitate of 
cuprous urate ; if an excess of sulphate of copper is added 
and then boiled, the red cuprous oxide will be precipitated. 
The oxygen from the cupric oxide is used for oxidation of 
the uric acid (we therefore find in the solution urea, allan- 
toine and oxalic acid). This alkaline solution of uric acid 
will also reduce nitrate of silver. If the two are mixed, in 
small quantities, upon the filter, there is found a black (if 
there be 1-1000 uric acid) or, (if 1-500,000 be present) a 
brownish yellow spot. 

By means of ozone, in the presence of an alkali, uric 
acid is converted into urea, ammonia, oxalic acid and car- 
bonic acid ; when the alkali is absent, into urea, carbonic 
acid and allantoine. 

Uric acid is a bibasic acid, and, as a result, two series of 
salts are formed, neutral and acid. 

The neutral salts are more readily soluble in water than 
the acid salts. Acid urate of soda requires 124 parts of 
boiling and 11 50 parts of cold water to dissolve it. There- 
fore, if we find urates in the sediment, we know that they 
are acid salts. On the other hand, if we find urates in so- 
lution, especially after the urine has acquired the tempera- 
ture of the room, we can assume that they are, principally, 
neutral. This view is supported by the fact that if an urine 
corresponding to the preceding is decomposed by a strong 
acid, muriatic or nitric, the whole urine, at first, becomes 
cloudy. If this cloudiness is examined under the micro- 
scope, we see that it is produced by amorphous points, which 
6 



42 EXAMINATION OF THE URINE. 

are acid urate of sodium. After having stood for some time, 
the milky cloudiness disappears, and in its stead appears a 
distinct crystalline deposit of free uric acid. This phenom- 
enon can only be explained by assuming that in the clear 
urine neutral urates were held in solution, from which, 
by the addition of acids, some of the base was deprived 
producing the less soluble acid urates. The acid continu- 
ing to act, all the base is taken from the urate, leaving free 
uric acid. 

In the reaction for albumen, when the nitric acid is poured 
under the urine, it is an established fact that frequently a 
layer is produced which, by the inexperienced, might be 
taken for the albumen precipitate. This, however, consists 
simply of amorphous acid urates, that are changed to uric 
acid on standing. 

The acid urates of sodium and ammonium will find con- 
sideration under the heading of sediments. The causes for 
the increase or diminution of uric acid have, as yet, not 
found a satisfactory explanation. 

Uric acid is considered as a preliminary step toward the 
formation of urea, although it is not at all probable that all 
the urea of the body is developed in this manner. From 
this the increase of uric acid was explained in all those con- 
ditions in which oxidation of the nitrogenous excretions is 
insufficient, either from the presence of too little oxygen or 
from the increased formation of uric acid, which is too great 
for the normal quantity of oxygen to dispose of. Many 
facts, however, do not harmonize with this explanation. 

Uric acid, as derivative of proteine compounds, has the 
same importance for the economy as urea. Usually, there- 



URIC ACID. 43 

fore, we find an increase of uric acid where urea is excreted 
in greater quantity. 

We find an increase of uric acid : 

i . In high living, either animal or vegetable diet, with 
little exercise in the open air. 

2. In acute febrile diseases, where nitrogenous com- 
pounds are decomposed. 

3. In diseases of the lungs and heart, accompanied by 
insufficiency of respiration, 

4. In all those cases in which the diaphragm is hindered 
from functionating properly; in large tumors of the abdo- 
men, ascites, etc. 

5. In leucaemia, either on account of increased produc- 
tion of uric acid by the diseased spleen, or on account of 
diminished oxidation by the blood, poor in red corpuscles. 

6. In the so-called uric acid diathesis. 

A diminution is usually found in chronic diseases of the 
kidney, diabetes mellitus (occasionally), urina spastica, hy- 
druria and arthritis. 

In order to determine, approximately, the quantity of uric 
acid in urine, the following may be used : Normal urine of 
1020-1024 sp. gr. neither precipitates, uric acid or urates, at 
the ordinary temperature, nor can we detect a precipitate 
upon using the nitric acid test. 

If concentration increases, there will be observed in the 
sediment a small quantity of free uric acid, and the nitric 
acid test will reveal a narrow layer. In these cases, how- 
ever, the specific gravity is already increased ; therefore, 
urea, and with it uric acid, are present in greater quantity. 
The quantity being normal, and we find much brick-dust 
sediment, and, in addition, urates in solution, or a consider- 



44 EXAMINATION OF THE URINE. 

able sediment of uric acid, the uric acid is increased. But 
if the quantity is diminished, this conclusion can not be 
drawn. In this case there may not be sufficient fluid pres- 
ent to dissolve the water at the ordinary temperature. 

For ordinary purposes it is safe to consider uric acid as 
diminished where urea is. All that has been stated refers to 
the quantity in percentage. If we wish to have an idea 
concerning the whole quantity, we must, naturally, take the 
quantity of urine passed in 24 hours into consideration. It 
is best to compare with normal urine. The average quantity 
is 1500 c. c. We must therefore add enough water to make 
up these 1500 c. c. in 24 hours. If we take the quantity in 
24 hours as 1000 c. c, we must add 500 c. c, or, to 10 c. c. 
of urine 5 c. c. of water. Two test tubes of equal diameter 
are selected; into one is put 15 c. c. of normal urine; into 
the other 10 c. c. of the concentrated urine, and to both are 
added 10 drops of muriatic acid, and then allowed to stand 
for 24 hours. From the precipitate we can easily determine 
whether the uric acid is increased or diminished in the urine 
that is compared with the standard. If the quantity is 
greater than 1500 c. c, the corresponding dilution of the 
normal urine must be had recourse to. 

III. Coloring Matter. 

In normal urine there occurs urine indican and a pig- 
ment, urobiline. Besides these well known bodies, there 
are found several other pigments that, however, have not 
been thoroughly studied. 

(a) Urobiline. 

Urobiline is a brown, resinous mass, readily soluble in 
water, but more readily in alcohol, ether and chloroform. 



UROBILINE. 



45 



Concentrated solutions are brown, varying from a yellow to 
a pink. They have no reaction with litmus, by reflected 
light show a beautiful green fluorescence, and with the spec- 
troscope possess a dark band of absorption between the 
Frauenhofer lines b and F. The fluorescence and spectro- 
scopic appearance become more distinct upon the addition 
of ammonia and a trace of chloride of calcium. Upon the 
addition of hydrochloric acid, however, the fluorescence 
disappears, and the absorption band approaches F y becomes 
fainter and has less marked outlines. If ammonia is added 
to the acid solution, its brown or red color is changed to a 
light yellow, approaching a green. Alkaline solutions show 
the same absorption band, and, at the same place as neutral 
solutions. 

In order to obtain urobiline, it is advisable to take dark fever urine. 
It is made strongly alkaline by ammonia, filtered, and then chloride 
of zinc is added until no precipitate is produced. This is washed 
upon the filter, first with cold, then with warm water, until nitrate of 
silver no longer produces turbidity in the water used for washing. 
Then it is boiled with alcohol, dried at a moderate heat, the powder 
dissolved in ammonia and precipitated with lead acetate. The pre- 
cipitate is then washed a little with water, decomposed with a mod- 
erate quantity of alcohol, containing sulphuric acid, and filtered. To 
the filtrate an equal quantity of chloroform is added, shaken, in order 
to remove the sulphuric acid, adding fresh water until this shows 
traces of color. Upon evaporating the chloroform, the urobiline re- 
mains in the form of a resinous mass. 

According to the researches of Maly, urobiline is a result 
of the reduction of bilirubine. As Hoppe-Seyler has suc- 
ceeded in producing a compound identical with urobiline, by 
means of acting on blood-coloring matter with hydrochloric 
acids and tin, and as, on the other hand, the injection of sub- 



46 EXAMINATION OF THE URINE. 

stances that destroy the blood corpuscles increases the form- 
ation of biliary coloring matter, we can hardly doubt that 
urobiline is the direct or indirect result of the reduction of 
haemoglobine, and therefore its increase is of interest to the 
physician. It is found in acute febrile diseases, and points 
to an increased waste of red blood corpuscles. 

Urine which, without any further preparation, shows a 
greenish fluorescence upon the addition of ammonia and 
chloride of zinc and the characteristic absorption line, can 
be put down as rich in urobiline. 

Scherer's urohaematine, Heller's urophaeine, Thudichum's uro- 
chrome, etc., are bodies for whose purity we have no guarantee ; in- 
deed, for urochrome and urohaematine Maly has shown that both 
contain much urobiline. 

(b) Urine-Indican. 

Since the time of Heller, it is known that an addition of 
hydrochloric acid to urine will produce a peach-blossom red, 
violet or deep blue discoloration. The red he attributed to 
urrhodine, the blue to uroglaucine, and the coloring matter, 
from which both arise, and which he conceived to be yellow, 
he called uroxanthine. Uroglaucine was also found in urine 
spontaneously putrid, and has been identified with the in- 
digo of plants. Uroxanthine was therefore considered the 
same as indican, the mother substance of indigo-white, which 
is found in many plants. Recent investigations have shown 
that these two substances are not identical. We will there- 
fore call these bodies urine-indican. 

This substance can be obtained pure by means of precipitating 
with acetate of lead, decomposing with ammonia; this precipitate, 
suspended in alcohol, is subjected to a current of sulphuretted hy- 



URINE-INDICAN. 47 

drogen gas, then filtered from the lead sulphide, evaporated with gen- 
tle heat, finally in vacuo over sulphuric acid. More complicated 
methods are known. For particulars, see Hoppe-Seyler, Chemische 
Analyse, p. 191. 

Urine-indican is not a glucoside, because, upon splitting 
it up no sugar is found; it is a bi-sulpho acid on account of 
the treatment with hydrochloric acids giving large quantities 
of free sulphuric acid. In the uncombined condition, these 
acid-ethers are unstable, and putridity, as well as the action 
of mineral acids, decompose them. Simultaneous, in both 
instances, there is an oxidation, so that the formation of in- 
digo does not depend solely upon a splitting up. The one 
product is indigo; a second is a red body, whose sublimate 
condenses to fine red needles, which might be identical with 
Heller's urrhodine. Upon the quantity of these two pro- 
ducts depends the color which is produced upon the addi- 
tion of hydrochloric acid to urine. 

When concentrated sulphuric acid is allowed to drop into urine 
from some height, the mixture is usually colored more or less dark red. 
This seems to depend upon various products (probably the splitting 
up of urine coloring matter). In the presence of sugar, albumen and 
constituents of the bile, undoubtedly all participate in the split- 
ting up, so that the mixture may become opaque and brownish black 
(Heller's urophseine test). As this mixture generates a considerable 
amount of heat, many substances, such as iodine, the odoriferous oil of 
cubebs, of sassafras, etc., escape, and are detected by the smell. In 
parenchymatous purulent processes in the bladder, an exceedingly 
offensive and penetrating odor is generated. 

The oldest test for indican is the uroxanthine test of 
Heller. 

1. This is carried out in the following manner : There 
is poured into a beaker 3-4 c. c. of pure hydrochloric acid, 



48 EXAMINATION OF THE URINE. 

and into this are dropped from 10-20 drops of urine, stirring 
the mixture with a glass rod. Under normal conditions, there 
is present only sufficient indican to give to the mixture a light 
yellowish-red tint. If the acid, however, becomes violet or 
blue, then the quantity of indican is greater than normal. 
The more indican there is present, the more rapidly does 
this change take place, and sometimes 1 or 2 drops of urine 
are sufficient to give to 4 c. c. of urine a blue tint. If after 
1 or 2 minutes no violet is perceived, then indican is not in- 
creased, even if the mixture should turn dark reddish-brown 
after standing for from 10-20 minutes. 

In the urine of jaundice, it is necessary to precipitate the 
biliary coloring-matter with acetate of lead, and filter before 
performing the test. 

The color in this test, unfortunately, is of little value, as it does 
not only represent the quantity, but also the varied capability, of de- 
composition of indican ; how inconstant this is, is proven by the fact 
that urine-indican produces, at one time more indigo blue, at another 
more indigo red. Above all, it must be observed that albumen, with 
hydrochloric acid, especially when the action has gone on for some 
time or it has been heated, shows a violet color. Notwithstanding 
this, the dark blue color may be looked upon as a sign of increase in 
indican. 

2. 10 c. c. of urine are mixed with equal quantities of 
hydrochloric acid, then drop either a saturated solution of 
chloride of lime, or simply chlorine water, into the mixture, 
and observe the color (Jaffe's test). 

3. Heat about 5 c. c. of urine, moderately, with double 
the quantity of nitric acid, then shake with chloroform, 
which takes up the indican. Finally examine the chloro- 
form extract with the spectroscope (Stokvis' test). 



URINE-INDICAN. 49 

If indol is introduced into the system, indican is very 
much increased ; the same occurs if the small intestine is 
ligated. The pancreas digestion produces, in its last stage, 
indol; by tying the intestine this is increased, absorbed and 
finally produces an increase in the urine-indican. The al- 
bumen of food, then, is a source of indican. In the ordinary 
putrefaction of albumen indol is generated. On the other 
hand, it is becoming more probable that a part of the albu- 
men in the body, on account of a fermentative process is di- 
vided up as it would be by putrefaction outside of the body. 
The albumen of the tissues, then, is the other source of in- 
dol, and therefore of indican. In this way may be explained 
"how, in fasting, indican does not entirely disappear from the 
urine, being formed at the cost of the disintegrating tissues. 

Indican is increased; in meat diet, in Addison's disease, in 
cholera, in cancer of the liver ; it is enormously increased 
in all diseases that produce a closure of the small intestine 
(incarceration, invagination, etc.); not so much in obstruc- 
tion of the large intestine ; ordinary constipation. It is very 
much increased in cancer of the stomach and peritonitis. 
In disease of the kidney, with the exception of the granular 
kidney, indican is not much increased. In general, chronic 
consumptive and inanition-processes increase it rather than 
acute diseases. Fever does not cause the same increase in 
indican that it does in urobiline. 

Increase of urine-indican in lesions of the central and peripheral 
nervous system has only been determined by means of the reaction 
for uroxanthine, and therefore awaits further, more accurate investiga- 
tion to make this result positive. 

7 



50 EXAMINATION OF THE URINE. 

IV. — Other Normal Organic Constituents. 

The remaining organic constituents, up to the present, 
possess very little value in aiding diagnosis ; we therefore 
will mention them but briefly : 

Kreatinine — the strongest base in the body — is passed in the same 
quantity as uric acid. The average quantity in 24 hours is between 
0.6 — 1.3 grammes. In vegetable diet the quantity is smaller than in 
animal diet. It has been found increased in pneumonia, intermittens 
and typhus ; diminished in inanition, advanced disease of the kidney. 

Hippuric Acid is found principally in the urine of herbivora. In 
human urine it is found in very small quantities. The average quan- 
tity is between 0.5 and 1.0 grammes in 24 hours. After eating cer- 
tain kinds of fruit (Reine-claudes, etc.), after the administration of 
benzoic acid, hippuric acid is increased. This is also the case in feb- 
rile diseases and in diabetes ; it is diminished when exclusive meat 
diet is used. If the quantity is increased very much, hydrochloric 
acid will cause a precipitate of hippuric acid just as it would of 
uric acid. 

Xanthine and the phenol-producing, disulphonic acid, are found in 
very small quantity in the urine. The former can only be obtained 
from several hundred liters of urine, in sufficient quantity for quali- 
tative tests. The presence of phenol-forming substances is detected 
by the phenyl reaction of the urine when this has been previously 
acidulated with a strong mineral acid. If tartaric acid, however, is 
used, the destillate of normal urine shows no phenol reaction, prov- 
ing that phenol (carbolic acid) exists in urine only in a combined 
state. 

Oxaluric Acid is found in very small quantity. It is the result of 
the indirect oxidation of uric acid. 

Oxalic Acid is found in the sediment in the form of its calcium salt. 

Concerning the existence of Sugar in normal urine, the authorities 
are divided. At all events, there is found in normal urine a sub- 
stance which, in common with the urates, will reduce copper sulphate 
in alkaline solutions. 



CHLORIDES. 5 I 

In normal urine the existence of Lactic Acid has not been posi- 
tively decided upon. In pathological urine two kinds of lactic acid 
are found; fermentation lactic acid, occurring in fermenting urine of 
diabetes; sarcolactic acid after phosphorous poisoning, in acute yellow 
atrophy of the liver, in malacosteon and trichinosis. 

B. — Normal Inorganic Constituents. 

i — .Chlorides. 

In human urine we find the chlorides to consist nearly ex- 
clusively of the chloride of sodium and very little chloride 
of potassium. The average quantity found in the urine 
of a healthy man for 24 hours is from 10 to 16 grammes 
(6-10 gr. chlorine). After urea, chloride of sodium is 
the principal constituent of urine — indeed, corresponding 
with this fact the urine possesses a salty taste. If a drop 
of urine is evaporated on a slide, and put under the micro- 
scope, there will be found, besides the rhombic plates of 
urea ; chloride of sodium in flat octohedra or incompletely 
developed crystals of the tessular system. 

It is frequently important for the physician to find out in 
an easy and quick manner whether the chlorides are in- 
creased or not. This can be done in the following way: 

If a solution of common salt is decomposed by nitrate of 
silver, a white precipitate of chloride of silver is produced : 

NaCl+AgN0 3 =NaN0 3 +AgCl. 

But if we have a solution which also contains phosphates, 
as urine, we must first acidulate with a little nitric acid be- 
fore making this test, so as to prevent the phosphoric acid 
from precipitating with the silver, thus increasing the latter. 
An unimportant inaccuracy is produced by the simultaneous 



52 EXAMINATION OF THE URINE. 

precipitation of uric acid. The nitric acid prevents the 
formation of phosphate of silver, but not of the insoluble 
chloride. If, for this test, a solution of nitrate of silver of 
constant strength (i in 8) is taken, we find that if single 
drops of this solution are added to y 2 — if solution of com- 
mon salt (as urine), they will fall to the bottom of the ves- 
sel in the form of cheesy masses, that are not subdivided 
upon shaking and never produce a cloudiness. If we have 
a very dilute solution, i-io^ and under, no masses are 
formed, but the whole fluid becomes equally milky and 
turbid 

This method can be utilized for the examination of urine 
in the following way : A wine-glass is taken, filled half full 
with urine, acidulated with nitric acid, and then i or 2 drops 
of the silver solution are added. If the drops come down 
as cheesy globules, the chlorides are not diminished ; if a 
milkiness is produced, they are very much diminished, and 
if this is wanting, they are entirely absent. 

The test for albumen can be made to serve for the test for salt. 
Stir the nitric acid with the urine, and then add the nitrate of silver. 
If much albumen is present, the coagulum must be removed by filtra- 
tion before performing the test for the chlorides. 

The chlorides are diminished : 

1. When the body is at rest (the night urine has a small 
quantity of chlorides). 

2. In all acute febrile diseases, especially if combined 
with serous exudations or watery passages. The quantity 
of chlorides is in direct ratio with the quantity of urine, and 
in indirect with the specific gravity and quantity of urea, 
until the acme is reached. As a rule, the kidney excretes 
only the excess of chlorides. In inflammatory processes 



CHLORIDES. 53 

common salt frequently collects in the exudations (pleuritis). 
On the whole, it can be said of the chlorides, in connection 
with acute processes, that an increased diminution of the 
chlorides indicates an increase of the disease, and vice versa. 

In pneumonia, for instance, the chlorides can be entirely 
absent without our being able to account for this by a di- 
minished introduction into the system. In typhus and men- 
ingitis they are diminished, but not absent. Absence of 
chlorides always indicates a grave affection. 

3. In chronic diseases, with diminished digestive powers, 
or dropsy. 

Increase of the chlorides is observed : 

1. When much salt is introduced. 

2. When much physical or mental labor is performed. 

3. During paroxysms of fever, either before or after. 
Throughout the 24 hours this is compensated for, so that the 
whole quantity is normal, or even sub-normal. 

4. In diabetes insipidus. 

5. In dropsy, as soon as diuresis has been established, so 
that the pent-up chlorides suddenly find an escape. 

2. — Phosphates. 

The whole amount of phosphoric acid is between 2.3 and 
3.8 grammes; in healthy men the average is 3.5 grammes. 
The diurnal variations can be very great. The quantity 
rises after the meal until evening (maximum), and falls dur- 
ing the night until the next morning (minimum). 
We find an increase of phosphoric acid in urine : 
1. After the introduction of phosphorus, phosphoric acid 
or the soluble phosphates into the organism. 



54 EXAMINATION OF THE URINE. 

2. When the diet is principally animal, and especially 
when food is taken that contains more or less prepared phos- 
phoric acid as brain. 

3. In all acute febrile diseases (not always). 

A diminution is found in all urine of low specific gravity : 
urina potus, urina spastica, etc. , in kidney and in heart dis- 
ease, with diminished urine; in serious disturbances of di- 
gestion, and in chronic brain troubles (except epilepsy). 

Phosphoric acid P0 4 H 3 is a tribasic acid, i. c, the three 
atoms of hydrogen can be displaced by metals. 

In urine this acid is partially bound by the earthy, par- 
tially by the alkaline bases (earthy and alkaline phosphates). 

(d) The earthy phosphates, /. e,, of calcium and mag- 
nesium are found, normally, in very small quantity (0.9-1.3 
grammes in 24 hours). Magnesium phosphate is present in 
about double the quantity of calcium phosphate. In acid 
urine we find these salts in solution; in alkaline urine, how- 
ever, they are found in the sediment. 

Phosphoric acid forms, with calcium, three salts: 

POj O y 

The neutral : f O [ Ca = " ( P0 «)2 Ca * 

PO-^ O 



(.O 

rofi 



Ca 



The single acid : PO j O j C a+ 2 H 2 0=P0 4 HCa+ 2 H 2 



OH 
PO-! OH 



The double acid : £ § j Ca+H 2 =(P0 4 H 2 ) 2 Ca+H 2 

Po5 OH 
(OH 



PHOSPHATES. 55 

The last combination is found dissolved in urine. A 
double magnesium-phosphate is ' not known. The single- 
acid is said to be held in solution in urine by free acid (?) 

The reaction for the soluble earthy phosphates is per- 
formed by alkalies (sodium, potassium, or ammonium). 

In calcium phosphate, acid is withdrawn thus : 

3 [(P0 4 H 2 ) 2 Ca]+i2KOH=(P0 4 ) 2 Ca 3 + 4 P0 4 K 3 +i2H 2 0. 

With magnesium-phosphate, on the other hand, ammonia 
magnesic-phosphate is formed if ammonium is used : 

P0 4 HMg+NH 3 +6H 2 0=P0 4 Mg(NH 4 )+6H 2 0. 

The crystalline form will be described in connection with 
the sediments. 

In order to test for the earthly phosphates, fill a test-tube 
one-third full with clear urine, add a few drops of caustic 
potassium or ammonia, and heat until the earthy phosphates 
precipitate in flakes; put the test-tube on a stand for 10-15 
minutes, so that the precipitate deposits, and then judge of the 
quantity. If we have used a test-tube about 16 c. long and 2 
c. in diameter, a layer of 1 c. in depth will represent the 
norm; if the layer is 2-3 c. high, the earthy phosphates are 
increased; if only a few flakes are present, they are dimin- 
ished. 

In normal urine they form a white precipitate ; if the urine 
contains abnormal coloring matter, this determines the color 
of the precipitate ; blood-coloring matter renders them blood- 
red or dichroic; vegetable coloring matter of rhubarb or 
senna, etc., pink or blood-red; biliary coloring matter, yel- 
lowish-brown and uroerythine gray. 

Diseases of bone, malacosteon, rhachitis, etc., extensive 
periostitis, chronic arthro-rheumatic processes; the introduc- 



56 EXAMINATION OF THE URINE. 

tion of mineral waters rich in calcium, medicines and exclu- 
sive meat diet (not constant), produce an increase of earthy 
phosphates. 

A diminution is observed in diseases of the kidneys. 

In alkaline urine the earthy phosphates are found in the 
sediment. 

(&) Alkali phosphates are represented (principally) by 
the acid phosphate of sodium and of potassium (traces). 

The tribasic phosphoric acid forms three alkali salts, de- 
pending on 1, 2 or 3 atoms of hydrogen being displaced by 
the metal : 

PO,H 2 Na P0 4 HNa 2 P0 4 Na 3 

(Double-acid, Sodium (Single-acid, Sodium (Neutral, 

Phosphate). Phosphate). Sodium Phosphate). 

Only the first has an acid reaction, and its presence pro- 
duces the acid reaction of urine. The other two have an 
alkaline reaction. All are readily soluble in water (in con- 
tradistinction with the earthy phosphates), even in alkaline 
water. 

Of the entire phosphoric acid found in urine two-thirds 
are bound to the alkalies. 

The reaction is best performed with the magnesia fluid 
(see Chap. IV., No. 10). If we want to examine for all of 
the phosphoric acid in urine, we add to 10 c. c. urine 3 c. c. 
of the magnesia fluid. There is produced a precipitate which 
is made up principally of ammonia-magnesic phosphate, 
with which amorphous calcium-phosphate is mixed. If the 
entire fluid becomes milky, the alkaline phosphates are pres- 
ent in normal quantity. If the precipitate becomes so dense 
as to give to the fluid the consistency of cream, then the 
phosphates are increased. If the fluid is simply turbid and 
very transparent, then there is a diminution. 



SULPHATES. 57 

This is a reaction for the entire phosphoric acid, but as the earthy 
phosphates are present only in such small quantities, they need either 
not be taken into consideration, or, with a little practice, one learns 
to subtract the quantity found by means of the test for the earthy 
phosphates from the result obtained by this test. 

If the earthy phosphates are present in very great quan- 
tity, they must be precipitated by ammonia, the urine fil- 
tered, and to this the magnesia fluid must be added. 

4. Sulphates. 

The sulphates found in urine are the neutral sulphates of 
sodium and potassium. 

The sodium salt, as is the rule everywhere, is found in 
greater quantity than the potassium salt. The quantity of 
sulphuric acid passed by the healty adult in 24 hours, is 
between 1.5 and 2.5 grammes — average 2.0 grammes. 

The reaction for sulphuric acid is performed in a man- 
ner similar to that for phosphoric acid. Into a test-tube is 
put 10 c. c. of urine, a few drops of hydrochloric acid are 
added in order to prevent barium-phosphate from being pre- 
cipitated, then add one-third the quantity (3-4 c. c.) of a 
solution of chloride of barium. The reaction takes place 
according to the following formula . 

BaCl 2 +Na 2 SO,=2NaCl+BaSO„ 

Sulphate of barium being the desired precipitate. The so- 
lution of chloride of barium can be previously acidulated 
with hydrochloric acid (Chap. IV., No. 7), this precluding 
the necessity of acidulating the urine. 

If there is produced an opaque, milky turbidity, then the 
sulphates are present in normal quantity ; if the consistency 
8 



58 EXAMINATION OF THE URINE. 

is changed to that of the cream, then they are increased, 
and if there is produced only a translucent turbidity, then 
the sulphates are diminished. 

A rough quantitative test has been described by J. Vogel. It de- 
pends upon the above reaction and is performed by taking 100 c. c. 
of the urine (2.00 grammes of sulphuric acid being voided in 24 hours 
with a quantity of 2,000 c. c.) and adding sufficient chloride of ba- 
rium solution to satisfy one-half the sulphuric acid contained in the 
100 c. c. of urine — i. e., 0.05 grammes. If upon the further addition 
of the test solution no precipitate is formed, then the sulphates are di- 
minished. If a precipitate is produced, then add the same quantity 
of the test solution that was originally employed, and again test. No 
precipitate being produced, the sulphates are normal. If a precipi- 
tate is produced upon the further addition of the fluid, the sulphates 
are increased. 

An increase of sulphuric acid or the sulphates is observed : 

1 . After the introduction of sulphuric acid, its soluble 
salts, of sulphur combinations, or of sulphur itself, into the 
organism. 

2. In exclusive meat diet, the sulphur of the albumen 
being oxidized to H 2 S0 4 . 

3. In acute febrile diseases, accompanied by free excretion 
of urea. Increase in the sulphuric acid, in this case, must 
be referred to an increased waste of those constituents of 
the body that contain sulphur. The highest degree is no- 
ticed in meningitis, encephalitis, rheumatism, and affections 
of the muscular system. 

A decrease in the sulphates occurs in exclusive vegetable 
diet, in the beginning of typhus and (in percentage) in all 
those urines that show diminished specific gravity. 

Other inorganic substances that have been found in urine are ; am- 
monia, iron and silicic acid. Traces of all only are found but for the 
first, Duchek claims that as fevers increase, so the ammonia increases, 
to diminish in reconvalescence. 



ALBUMEN. 59 

C. — Abnormal Constituents, 
i. Albumen. 

Normal urine ought never to contain albumen. In patho- 
logical conditions, however, notably in diseases of the kid- 
ney, albumen is frequently found in great quantity. 

After the taking of much albumen of eggs, CI. Bernard, 
Becquerel and others have observed albumen in otherwise 
perfectly healthy urine. Serum albumen (up to o.i %) may 
be present in the urine of perfectly healthy persons. We 
have reported several cases (Wiener Med. Presse, 1870,) and 
also Vogel. The cause for this is unknown. The urine was 
somewhat concentrated, very acid and contained more urea 
and uric acid than normal. In the sediment we sometimes 
found nothing, sometimes crystals of uric acid or oxalate of 
lime. It is probable that this albuminuria, periodic and pre- 
senting variable quantities of albumen, was due to the chem- 
ical composition of the urine. It might, also, be attributed 
to certain abnormal nervous conditions of the kidney. At 
all events, these cases are of such rare occurrence that the 
presence of albumen must be considered as abnormal. 

Why albumen is not found in the healthy condition is best 
explained by the mechanical theory of Ludwig. 

Graham divides all bodies into crystalloids and colloids 
the first, those that diffuse readily through animal membranes; 
the second, those that diffuse with difficulty or not at all and 
do not crystallize. This division, applied to albumen, will 
show that serum albumen is a colloid, for it does not crys- 
tallize, nor does it pass through animal membranes unless 
increased pressure is applied. The crystalloids passing so 
readily through membranes and the colloids with such diffi- 



60 EXAMINATION OF THE URINE. 

culty, it is natural to assume that the molecule of albumen 
must be larger than that of any c; ys tallizable salt. The 
probability for this increases when we consider the facility 
with which foam is produced in albumen solutions, and also 
its complicated chemical structure. The latter finds expres- 
sion in the formula C 216 H 169 N 27 S 3 68 . 

According to Ludwig we have in the glomerulus, a process 
of transudation, while throughout the course of the tubules 
we have one of diffusion. The two fluids, blood and the 
water of urine, are always found separated by animal mem- 
brane. These septa have the property of allowing the crys- 
talloid substances of the blood (salts, urea, etc.,) to pass 
through readily, but not the albuminoids, under the con- 
ditions of pressure in the kidneys, therefore we cannot expect 
to find albumen in normal urine. 

If we find albumen, then the blood pressure in the vessels 
of the kidney is usually increased (passive hyperaemia, val- 
vular heart disease, amyloid degeneration of the vessels, etc. ) 
or the membrane, in some place, has become pervious (pa- 
renchymatous nephritis, Bright' s disease). 

Albumen is found in urine most frequently as serum albu- 
men and paraglobuline. If other fluids that contain albumen 
(blood, pus, exudations, etc.,) are present in the urine we will 
find that form of albumen that is characteristic of these. 
Fibrine is found in copious hemorrhages and croupous affect- 
ions of the urinary apparatus. 

True fibrinuria, a so-called coagulable urine, that is 
said to occur frequently in Isle de France, is, with us, a very 
rare occurrence. We observed this, temporarily only, in 
three cases of papillomatous tumors of the bladder. But we 
not infrequently find urine having the consistency of honey 



Albumen. 6i 

or syrup, depending upon pus dissolved in alkalies, not upon 
fibrine. This form of urine becomes thin upon the addition 
of water, and acetic acid produces a white precipitate of al- 
kali-albuminate. This being produced by the action of am- 
monium carbonate on the serum-albumen of pus. 

For albumen there are many characteristic reactions; for 
the urine, however, two especially are of value, — the concen- 
trated nitric acid test and boiling. 

i. In carrying out the nitric acid test about ten c. c. of 
of urine are put into a glass (best a wine glass or a sherry 
glass), and under this is poured pure, colorless, concentrated, 
(not fuming) nitric acid. The reagent is poured under the 
urine by means of holding the glass containing the nitric 
acid at an angle with the one containing the urine and allow- 
ing the acid to flow gently along the side of the latter. At 
the place where the acid and urine touch there appears, when 
albumen is present, a band-like zone, having both upper and 
lower boundary-line sharply defined. This can only be 
mistaken for resins (copaivic acid) or the urates; the latter, 
when present in great quantity, also precipitating upon the 
addition of nitric acid. But this layer does not appear 
where urine and acid touch, but higher up ; neither is its 
upper margin sharply defined, resembling more a cloud of 
smoke, slightly curly in the middle. 

If albumen and the urates are present at the same time, 
two white layers, superimposed, will be obtained. The 
lower one being albumen, the upper the urates. Both are 
separated from each other by a layer of clear urine. 

The precipitate produced by resins is dissolved by the ad- 
dition of a few drops of alcohol. 

If this test is performed with normal urine, there will be 



62 EXAMINATION OF THE URINE. 

observed between urine and nitric acid a brown ring of 
coloring matter which, in a few minutes, increases in in- 
tensity. We now comprehend how in fever urine, rich in 
coloring matter, which at the same time may contain albu- 
men, the ring of albumen will be, not snowy white, but, 
more or less, brownish. If much indican is present the al- 
bumen frequently appears pink or violet ; in the presence of 
blood-coloring matter, red and with biliary coloring matter, 
not decomposed, of a green color. If urine is very much 
concentrated, there will be produced a copious crystalline 
deposit which, under the microscope, will reveal itself as 
nitrate of urea. Urine, rich in uric acid might produce free 
uric acid in the form of yellowish whetstones, which can be 
readily differentiated from the preceding precipitate by its 
insolubility in water. 

If urine contains much carbonic acid, either on account 
of its being alkaline and having much carbonate of am- 
monia, or being neutral or acid, having sodium carbonate 
or free carbonic acid gas (as is frequently the case in the 
use of mineral waters), then there will be observed upon 
the addition of nitric acid an effervescence of the fluid. 

If this test does not convince to satisfaction, then the next 
must decide ; indeed, it is always best to perform both tests. 

2. The test by boiling is performed in that we take 8-10 
c. c. of urine, if it be acid, and boil it in a test tube. It 
is always safer to add 1-2 drops of acetic acid. A flaky 
cloudiness indicates albumen. If the urine is neutral, faintly 
acid or alkaline, a precipitate may show itself on boiling, 
which, upon the addition of acetic acid, again dissolves. 
This is not albumen, but the earthy phospates that have been 
held in solution by carbonic acid gas, which, being driven 



ALBUMEN". 6$ 

out by heat, no longer can dissolve. That which has only 
been done, as a precaution in acid urine, must always be done 
in alkaline or neutral urine in order to prevent deception, 
viz : first acidulate the urine. 

By means of this test, albumen is not only simulated, but 
in alkaline urine it may entirely escape detection. The 
nitric acid test frequently fails us here, on account of the 
effervescence produced by the reaction upon the carbonates. 
If we do not acidulate, the alkali present may be sufficient to 
change the albumen to alkali-albumen, which does not pre- 
cipitate upon boiling. If we are not careful, on the other hand, 
with the addition of acetic acid we may err on the other side, 
producing acid albumen, which can not be precipitated by 
boiling. In the presence of very small quantities of albumen, 
its detection becomes a very difficult matter if the urine is al- 
ready cloudy or does not come through the filter as clear 
urine. Alkaline urine is already more or less turbid, contains 
no earthy phosphates in solution and must always be clari- 
fied before proceeding to test for albumen. In order to do this 
the urine must be boiled witb : _ ::' its volume of caustic pot- 
tash (Chap. IV., No. 5.) and filtered. If the filtered urine 
not clear 1-2 drops of the magnesia fluid must be added, the 
urine again heated and filtered. If this is then carefully 
acidulated with acetic acid the slightest turbidity of albu- 
men will be detected. This becomes more distinct when 
ferro-cyanide of potassium is added to the already acidu- 
lated urine ; there will then be noticed upon the bottom of 
the v hite flakes of albumen. 

It is advantageous to know other tests. 

(a) Acidulate the urine with acetic acid, add an equal volume of 
a cold saturated solution of sodium sulphate, and boil. 



64 EXAMINATION OF THE URINE. 

(b) Into filtered urine there is dropped saturated solution of picric 
acid. If cloudiness is produced, albumen is present (Galippes test). 
Only the cloudiness that is produced instantly is decisive. 

Albumen is found in urine : 

i. When the blood-pressure in the Malpighian tuft is 
greater than normal. This occurs in all anomalies of circu- 
lation (valvular lesions of the heart, passive hyperaemia, 
amyloid and atheromatous processes in the arteries, etc). 

2. In all those diseases in which a change in the diffu- 
sion-membrane, f. e., the walls of the tubule with its epithe- 
lium and its arterioles and capillaries, can be demonstrated 
(parenchymatous nephritis, Bright' s disease, etc.). 

3. When there is mixed with the urine, blood, pus or any 
other fluid containing albumen (false albuminuria). 

4. Occasionally in hydraemia (disturbance of nutrition 
in the capillaries). 

It is also thought (Vogel) that albuminuria can arise from 
the formation in the blood of a peculiar kind of albumen,, 
endowed with different properties of diffusion, being even 
able to pass through the perfectly intact membrane. We 
have never been in the position, however, to verify this 
view. 

In true albuminuria it is important to be able to determine 
the quantity of albumen excreted in 24 hours, for only by 
means of this can we determine whether or not improve- 
ment is taking place. The most accurate quantitative anal- 
ysis of albumen is made by means of the scales or the po- 
lariscope (Chap. V.). These methods, however, are too la- 
borious and consume too much time for the practicing phy- 
sician, and we therefore desire a method by which we are 
enabled to state when albumen is present in great (1-2%) 



ALBUMEN. 63 

or in small (}4%) quantity. This can be accomplished, 
with a little training, by means of observing the albumen- 
zone produced in the nitric acid test. If this zone is faint, 
whitish, not granular, more or less translucent, and only to 
be distinguished as a sharply-defined band when placed 
against a dark background, and, above all, is only between 
2 and 3 m. m. high, then we know that albumen is present 
in very small quantity (below ^%, usually 1 part in 1,000). 
If this zone is between 4-6 m. m. high, white, opaque, per- 
ceptible without a dark background, granular, then albumen 
is present in moderate quantity (}{-}£%). But when, upon 
the addition of nitric acid, the albumen precipitates in 
flakes or granules, sinks to the bottom in small masses, and 
when upon stirring this mixture with a glass rod the urine 
has the appearance and consistency of cream, then the 
quantity of albumen is very great (1-2% and above). 

Similar results can be obtained with the boiling test. 
Take a test-tube and fill it one-third full with clear, filtered 
urine (if alkaline, acidulate with acetic acid). A very slight 
turbidity, which permits the urine to appear translucent after 
boiling, simply causing opalescence, indicates a small quan- 
tity of albumen. If the urine is milky, upon boiling, the 
albumen separating in fine flakes, and upon settling, we find a 
layer at the bottom of the test-tube of a finger's height, then 
albumen is present in moderate quantity. But if the albu- 
men separates in coarse flakes, and not, as before, from the 
upper surface of the fluid, but where the flame touches the 
tube; if the urine appears thick, like cream, after boiling, 
then albumen is present in very great quantity. If we wish 
to compare the quantities of albumen of one day with that 
of another, it will be necessary to boil in test-tubes of equ< 1 
9 



66 EXAMINATION OF THE URINE. 

diameter, taking the same quantity of urine, and then com- 
pare the height of the sediments. It is better to use glass 
tubes of equal diameter, that are closed by means of a 
cork, wrapped in wax paper. After 24 hours we can 
measure, with a rule, the depth of the albumen layer 

The preceding are short directions for approximate 
analysis, but they must be frequently exercised, and only he 
who has made himself perfectly familiar with the appear- 
ances can draw reliable conclusions. 

What has been said is true for the majority of cases, where 
the principal quantity of albumen is serum albumen. 

At the same time, or independently, we frequently find 
modifications of albumen, of which the most important is 
globuline (perhaps myosine). 

Peptone is found in every urine containing albumen ; in diseases in 
which there is a very high temperature it is sometimes found, even 
without the presence of albumen. 

In order to detect globuline, we dilute the urine until it 
has reached a specific gravity of 1002. Then we carefully 
add very dilute acetic acid (it is soluble in the concentrated 
acid). There usually appears a cloudiness. In order to 
precipitate all the globuline, allow a slow current of carbonic 
acid gas (bubble after bubble) to pass through the urine for 
1-2 hours. If allowed to stand for a time, the globuline 
separates in the form of a white powder. The fluid can 
then be tested by the other methods for serum albumen. If 
the sediment is made up of globuline, it must be soluble in 
a few drops of concentrated solution of common salt. 

Globuline is found in considerable quantities in catarrh of 
the bladder, acute nephritis, and especially in the amyloid 
kidney, whilst it is said that in chronic Bright' s disease it is 
present in very small quantity, or even entirely absent. 



SUGAR. 67 

2. Sugar. 

(C 6 H 12 6 )+H 2 0. 

The sugar of urine (identical with grape sugar) is, accord- 
ing to Briicke, a normal, constant constituent. But it occurs 
in such small quantity that, when using Trommer's test, not 
even a slight yellow precipitate is perceptible. Only a dis- 
coloration is observed. In abnormal urine, and especially 
in diabetes mellitus, we frequently find so great a quantity 
of sugar that it imparts a sweet taste to the urine, and when 
clothes are moistened with the latter, after the water has evap- 
orated they look as if they had been dipped into honey. 

Sugar of urine crystallises in warty concrements that con- 
sist of cauliflower leaflets. 

Of the many tests, the following are usually sufficient : 

1. Heller's Test. Mix, in a test-tube, urine, with one- 
half its volume of caustic potash, or soda solution (1 to 3), 
and boil. First the earthy phosphates are precipitated; 
these can be filtered if they are present in very great quan- 
tity ; as soon as the fluid is heated it is colored lemon, yel- 
lowish-brown or brownish-black, according to the quantity 
of sugar contained. If to this mixture a few drops of nitric 
acid are added, the dark color disappears, and an odor of 
caramel becomes perceptible. 

If the urine contains much albumen, it is advisable to re- 
move this first by boiling. 

If urine is of high color, which rarely happens in diabetes 
mellitus, it can be decolorized by means of sugar of lead 
solution (the sub-acetate precipitates a small quantity of 
sugar), or by filtering through animal charcoal. The latter 
must afterward be washed with water, because it will retain 
much sugar. 



68 EXAMINATION OF THE URINE. 

If this change in color takes place while the urine is cold, then bil- 
iary coloring matter is usually present. This change will even appear 
when the coloring matter is already decomposed, i. e., when neither 
Gmelin's nor Heller's tests will indicate its presence. In this case 
this test, especially when the addition of sulphuric acid produces a 
very dark color, is a very good one for biliary coloring matter. 

According to Badecker, if urine is mixed with caustic potassa and 
exposed to the air, there gradually appears a brown discoloration, the 
urine absorbing much oxygen and containing a body which he called 
alkaptone. This, like sugar of urine, reduces copper, but not bismuth 
salts. Probably this body is pyro-catechine. 

A beautiful reaction is produced by Mulder's test. Mixing urine 
with a solution of indig-carmine, first made alkaline with sodium car- 
bonate and boiling, the blue mixture first becomes green, then purple, 
and finally yellow. Shaking the boiling mixture and exposing to oxy- 
gen, it again comes back to the original blue. 

2. Trommer's Test. As before, mix with the urine caus- 
tic potassa or soda solution, and add drop by drop, shaking 
constantly, a solution of copper sulphate (i to 10) until a 
clear, blue fluid is obtained. Then heat over a lamp. If 
sugar is present, reduction of the oxide of copper takes 
place in the following manner : First, yellow cuprous hy- 
drate is precipitated ; this losing its water, leaves red cuprous 
oxide. If the test-tube is put aside, and we wait a few min- 
utes, there will be observed a metallic mirror covering the 
bottom of the tube. Albumen must be removed by coagu- 
lation. If this is forgotten, a violet color, upon the addition 
of the reagents, will be a reminder of its presence. If neither 
sugar nor albumen is present, then we get a turbid grayish 
green fluid, but no reduction of the oxide. 

Large quantities of creatinine, peptone, etc., can prevent the pre- 
cipitation of the cuprous oxide. 



Sugar. 69 

3. Bbttger*s Test, Mix the urine with the alkali, as above, 
then add as much bismuth — a mixture of basic bismuth ni- 
trate (BiO)N0 3 +BiO,OH with bismuth nitrate (BiO)N0 3 -f 
H 2 — as will cover the end of a knife-blade, and then boil. 
After a time, a mirror of bismuth appears on the test-tube. 
If small quantities of sugar are present, then the bismuth is 
only colored gray, because only a part of it is reduced — the 
reaction may even be covered over by the excess of bis- 
muth. 

If albumen is present, this must be removed, otherwise 
bismuth-sulphide may be produced, which may be mistaken 
for an oxide of bismuth. In order to be certain, it is well 
to add to a portion of urine that has been made alka- 
line, acetate of lead ; if a black precipitate is formed, it is 
conclusive evidence of the presence of a sulphur compound. 

Briicke recommends, in order to remove all disturbing substances 
Frohn's reagent (1.5 grammes precipitated, unwashed bismuth nitrate 
are heated to the boiling point with 20 grammes of water, then 7.0 
grammes of iodide of potassium, and finally 20 drops of hydrochloric 
acid added). A modification has been proposed by Maschke, he 
using a solution of tungstate of soda. 

Heller's test is the simplest and the best, and has the ad- 
vantage that with it, one skilled in its use, can tell the ap- 
proximate quantity of sugar present. Second comes Bott- 
ger's test, for when no albumen is present, no other sub- 
stance except sugar will reduce the bismuth. Trommer's 
test is least reliable, for many other substances, when pres- 
ent in the urine in large quantities, will reduce the copper 
salt : uric acid, the urates and hippuric acid. Many speci- 
mens of urine from patients with acute febrile diseases, 
where the urates are present in great quantity, are diagnosti- 



70 EXAMINATION OF THE URINE. 

cated as containing sugar, especially if reliance is placed on 
the yellow discoloration, not waiting for the precipitate of 
cuprous oxide. For all cases, the most reliable tests are by 
fermentation and with the polariscope, both, however, too 
laborious for the practioner. 

If we have demonstrated the presence of sugar, it is of 
equal importance to determine the quantity present and the 
amount passed in 24 hours. The exact quantitative tests 
will be discussed hereafter — they alone are reliable. Approxi- 
mately this has been determined by the specific gravity; the 
higher this is, the more sugar is supposed to be present. 
This, however, is only true for a pure solution of sugar, not 
for so complex a fluid as urine, and Bence Jones has shown 
that the method can not even be utilized for rough estimates. 

The second method is that of Vogel, and depends upon 
the intensity of the color produced with the potassa test. It 
is very useful for the practitioner. If we make solutions of 
grape sugar of different strength and test them, in test-tubes 
of equal diameters, a scale can be easily constructed which 
will suffice for ordinary rough estimates. Mix two parts of 
the solution with one of liquor potassa, and boil. A 1 % 
solution will give a canary-yellow; a 2^, a dark amber; a 
5%, a dark rum, and a 10% solution will become dark 
brown and opaque, while all other solutions are more or less 
transparent. Taken in connection with the specific gravity, 
this test is very useful, as diabetic urine is usually of a very 
pale color. 

Sugar only occurs, in large quantities, in one form of disease : gly- 
cosuria. 

Temporarily it is found in certain injuries of the brain. In 
very small quantities it is said to appear in the urine of acute febrile 



Leucine and Tyrosine. 71 

diseases, spontaneous gangrene, pneumonia, typhus, rheumatism, 
acute encephalitis, in diseases of the nervous system, especially of 
the cord, in cachexias, and similar processes ; also, after the introduc- 
tion of turpentine, nitro-benzole, nitrite of amyl, etc. 

Xeukomm and Vogel, exceptionally, have found inosite, both alone 
and with grape sugar. It is also to be found in Bright's disease. 

Some patients suffering with diabetes have a breath that smells of 
chloroform. The urine, odorless immediately upon being passed, after 
a short time also begins to smell of the same substance. Upon the 
addition of chloride of iron, it usually turns reddish-brown. In the 
distillate of such urine is found both acetone and alcohol, the result 
of the splitting up of ethyl-diacetic acid. 

C 6 H 10 O 3 + 2 H 2 O==C 3 H 6 O+C 2 H 6 O+CO 2 +H 2 O, 

(Ethyl-diacetic acid.) (Acetone.) (Alcohol.) 

In women, 24-48 hours after ablactation and during nursing (when 
the milk for any reason is not withdrawn sufficiently), there appears 
in the urine sugar of milk. 

III. Leucine and Tyrosine. 
C 6 H 13 N0 2 and C 9 H n N0 3 . 

Leucine and tyrosine result from the decomposition of al- 
bumen and its nearest derivatives. They are found in great 
quantities in certain glandular organs of the body, when 
these are subjected to definite pathological changes ; in the 
liver, the pancreas, the spleen, etc. In the urine they have 
been found only in acute yellow atrophy of the liver, in 
several cases of phosphorous poisoning, and, in small quan- 
ties, in typhus and variola. 

If these substances are present in large quantity (usually the 
case in acute yellow atrophy of the liver), their detection is very sim- 
ple. Either we find the crystalline tyrosine in the urine, or it, 
with the leucine, separates, when the urine is concentrated in a 



7 2 



EXAMINATION OF THE URINE. 




water bath. Occasionally! 
these bodies occur in sol 
great quantity that they! 
partially take the place of I 
urea. They can be recog- 
nised by their characteristic! 
microscopic forms. (Fig. 
4. a, Leucine. b, Tyro-j 
sine.) If they are not veryl 
abundant, and do not ap- 
pear upon concentrating thel 
urine, a large quantity ofl 
urine must be taken, precip- 
itated with basic acetate! 
of lead, filtered, then the ex- 1 
cess of lead removed bysul-" 
phuretted hydrogen, again *"9* *• 

filtered, and then the clear fluid evaporated in the water bath down to a 
small volume. If tyrosine is present, there will be observed a crystalline 
deposit, after 24 hours. Leucine, which is more soluble, takes a 
longer time to be deposited. // is necessary to examine the urine as soon 
as possible after it has been voided. 

When leucine and tyrosine are present in large quantity, 
great degeneration of the albuminoids is always indicated. 

Albumen is nearly constantly found at the same time. 
Frequently oxymandelic acid C 8 H 8 4 (perhaps derived from 
tyrosine), which, up to the present, has never been observed 
anywhere else, is found. 

IV. Abnormal Coloring Matter. 



We must here discriminate between those substances that, 
being found normally in other fluids of the body, would 
here be considered abnormal, those that are found only in 



UROERYTHRINE. 73 

the urine, as uroerythrine, and finally those that are entirely 
accidental, as the coloring matter of plants. 

(a) Uroerythrine (Harley's Urohaematine). 

In all febrile diseases the urine has more or less of a yel- 
lowish-red color (urina flammea), and the expert, in most 
cases, is enabled from the condition of the urine alone to 
diagnosticate a febrile state. This color, according to Hel- 
ler, comes from the presence of uroerythrine (besides in- 
crease of the normal coloring matter). When such urine 
has a sediment, this is red or dark red ; even the clear urine, 
when precipitated with lead acetate, will cause a pink or 
flesh-colored precipitate of lead. Heller calls this red col- 
oring matter, found in solution or in the so-called brick-dust 
sediment, uroerythrine. 

It is said that this coloring matter contains iron; concerning its 
structure and origin, however, nothing definite is known. It is possi- 
ble that, in diseases in which there is blood dissolution (typhus, sep- 
tic fever, etc.), a part of the blood corpuscles in retrograde metamor- 
phosis supply material for the formation of the uroerythrine. The 
uroerythrine, then, could be taken as measure for the quantity of red 
blood corpuscles destroyed during fevers. 

This coloring matter is either discovered by the presence of a 
brick-dust sediment, or, when in solution, by the precipitation with 
lead ascetate above described. Only a small quantity of lead acetate 
in solution must be added, as it is not advisable to dilute the color 
in a great precipitate. If the urine contain blood coloring matter, 
this must be removed. The foam of urine containing much uroery- 
thrine may be yellow, like that of an icteric urine. In the latter, the 
precipitate with lead is also yellow. 

The earthy phosphates, when precipitated with liquor- 
potassa, appear gray, while in urine containing blood-coloring 
10 



74 EXAMINATION OF THE URINE. 

matter, they are red or dichroic. The absence of albumen, 
the color of the earthy phosphates and the red precipitate 
with lead, are the points of differential diagnosis between 
uroerythrine and blood-coloring matter. 

Uroerythrine is found in all febrile diseases, even in the 
mildest catarrh ; it is found in greatest quantity in pyaemia, 
diseases of the liver and lead colic. 

(Z 3 ) Coloring Matter of Plants. 

Many vegetable substances, especially chrysophanic acid 
(in rhubarb, senna, etc.) impart to alkaline urine a reddish 
yellow to deep red color. They can be recognized in that 
the red alkaline urine, upon the addition of an acid, turns 
yellow, but after the addition of ammonia again returns to 
its original red. In the test for the earthy phosphates of an 
urine containing such coloring matter, these will come down 
colored blood-red, so that one would be tempted to think of 
the presence of blood. But the earthy phosphates are never 
dichroic, and, upon being exposed to the air, turn violet. 
The differentiation from uroerythrine and blood-coloring 
matter is accomplished by the absence of a response to the 
test for blood-coloring matter, the absence of albumen, and 
by the characteristic changes upon addition of acids and al- 
kalies. It is important that the practitioner be perfectly 
familiar with these tests, especially in summer when the urine 
is apt to become alkaline, the blood-red appearance of the 
urine may be alarming without signification. 

(7) Blood-Coloring Matter. 

The occurrence of blood-coloring matter in urine may 
have a double source. Either it has been excreted by the 



Blood-Coloring Matter. 75 

kidneys, or the blood-corpuscles that have, originally, been 
mixed with the urine, have been dissolved. The color of 
the urine varies in that haemoglobine or methaemoglobine 
are present. 

In hemorrhages from larger vessels the urine usually con- 
tains haemoglobine. In parenchymatous or capillary hem- 
orrhages the urine usually contains methaemoglobine as well, 
which imparts to it a brownish-red color. The explanation 
why haemoglobine should occur in the one case, and me- 
thaemoglobine in the other, is probably to be found in the 
fact, that in hemorrhages from the capillaries the urine and 
blood are more intimately and more slowly mixed, and are 
retained longer at the temperature of the body. The most 
important factors for the change from haemoglobine to me- 
thaemoglobine are, probably, temperature, the presence of 
carbonic acid, and the absence of oxygen in the urine. 

In order to demonstrate blood-coloring matter in the 
urine, the haemine test is advantageous. Precipitate the 
earthy phosphates in a test tube : these will bring down with 
them the blood-coloring matter, appearing red. If little 
blood-coloring matter is present, they are dichroic. 

If the urine is alkaline and the test does not bring down 
the earthy phosphates, because they have already been re- 
moved with the sediment, then we can produce a precipitate 
with 1 or 2 drops of the magnesia solution, which will serve 
our purpose perfectly. 

This precipitate obtained on a filter, then placed upon a 
slide, dried carefully by means of gentle heat, and we can 
obtain the haemine crystals directly from it. To this end 
place a small quantity of common salt upon the dried earthy 
phosphates and rub it up well, with a knife. Then blow 



76 EXAMINATION OF THE URINE. 

the excess of common salt from the slide, place a hair upon 
the mixture, and upon it a thin cover over the remaining 
powder, after having added glacial acetic acid; then heat 
until bubbles begin to form under the covering glass. After 
cooling, haemine crystals can be seen with the microscope. 
The precaution must be taken, in order to avoid further de- 
composition of the blood-coloring matter, to heat carefully 
with the liquor potassa and to filter rapidly. Bubbles will 
also develop under the cover if the slide be allowed to stand, 
without heating, but these are carbonic acid gas. Allow 
these to escape, and then heat to the boiling point of the 
glacial acetic acid. The crystals prepared in this manner 
frequently appear very small and imperfectly crystallized, but 
they can be readily distinguished by means of using higher 
powers. 

Another method consists in making the urine alkaline with caustic 
soda, adding tannic, then acetic acid. The precipitate washed and 
filtered is then tested for haemine crystals. 

The crystals may also be obtained by coagulating the al- 
bumen, collecting the brown coagulum upon a filter, drying 
and testing with alcohol containing sulphuric acid. Evapo- 
rating the alcohol, the residuum is treated in the above 
manner for Teichmann's haemine crystals. 

If we have a spectroscope at our disposal, a large test 
tube is filled with the diluted urine, placed between the 
lamp and the instrument, and we will then observe the char- 
acteristic spectrum. 

So-called haematinuria occurs in diseases of the general 
system; scorbutus, purpura, scarlatina, etc., after transfusion 
of blood, after inhalation of arsenetted hydrogen — that dis- 



BILIARY COLORING MATTER. 77 

solved blood-coloring matter is found in cases of true haema- 
tinuria hardly needs to be mentioned. 

(<5) Biliary Coloring Matter. 

In certain conditions, biliary coloring matter, decomposed 
or not, can be found mixed with urine. The urine contains 
biliprasine more frequently than bilirubine; frequently other 
results of oxydation. If bilirubine is present, unchanged, 
then the proper tests will give a beautiful and characteristic 
play of colors ; if biliprasine is present, these will produce 
only a green color; but if the coloring matter has been 
changed beyond this, the tests are negative. 

For the detection of unchanged biliary coloring matter 
(bilirubine and biliprasine), the following tests may be used : 

1. Gmeliris Test, Pour under icteric urine concentrated 
nitric acid containing a small quantity of hyponitric acid. 
When the two fluids touch, the following colors in the fol- 
lowing order will appear : green, blue, violet, red, yellow. 
Green predominates, while blue is frequently not present. 
This test can also be performed by mixing urine with diluted 
nitric acid, and then pouring concentrated sulphuric acid 
under the mixture, 

2. Heller's Test. Pour into a small beaker 6 c. c. of pure 
hydrochloric acid, and then add urine, drop by drop, until 
the acid becomes faintly colored. Mix, and then pour pure 
nitric acid under the mixture. Again the play of colors will 
be observed when the fluids meet. If the fluids be mixed 
together, this play of colors will take place in the whole 
mixture. The play of colors can be observed especially 
well by means of a transmitted light. This test is very del- 
icate, easily executed, and sufficient for nearly all cases. 



78 EXAMINATION OF THE URINE. 

If we wish to detect small quantities, it is necessary to 
shake ioo c. c. of urine with 10 c. c. of chloroform in a 
bottle until the fluid is tinged yellow. Avoid too energetic 
shaking, as this will so finely subdivide the chloroform that 
it will no longer unite in large drops. Closing the bottle 
with the thumb, and lifting the latter, it is easy to allow i c. 
c. of chloroform to drop into a test-tube containing 10 c. c. 
of pure hydrochloric acid. If, then, a small quantity of ni- 
tric acid is added, and the whole shaken, the characteristic 
play of colors of Gmelin's test will be observed in the drop 
of chloroform. Because this play of colors takes place 
slowly, and because acids act very slowly upon this coloring 
matter dissolved in chloroform, this test is especially valu- 
able for the purpose of demonstration. 

In all reactions of biliary coloring matter, the green color 
is the deciding tint. If this has not been observed, the 
presence of this coloring matter can not be deduced. Indi- 
can, for instance, will also give blue, violet and reddish-yel- 
low, with Heller's test, but the characteristic green is want- 
ing. 

In testing for albumen with the nitric acid test, if unchanged bil- 
iary coloring matter is present, a green zone will be observed between 
the urine and the colorless nitric acid. If albumen is present, it is 
colored green by this test. Urine containing indican, however, may 
even here simulate biliary coloring matter. A blue layer is produced, 
which, by reflected light, looks green. In these cases, either perform 
Heller's test with the chloroform or precipitate the urine with lead 
acetate, and see if it is possible to detect indican, in quantities, in the 
filtrate. 

3. Ultzmanris Test. This strives to bring out the char- 
acteristic green color positively and surely. Add to 10 c. c. 



BILIARY COLORING MATTER. 79 

urine 3 — 4 c. c. solution of caustic potassa (1 in 3 of water), 
shake, and then acidulate with pure hydrochloric acid. The 
mixture turns emerald green. 

If the earthy phosphates are precipitated from urine con- 
taining biliary coloring matter, they come down with a 
brown color. 

If the coloring matter is so much changed that the pre- 
ceding tests are negative, then the following will be of ser- 
vice : Dip a piece of clean, white linen (or filtering paper) 
into the urine, and allow to dry. The linen will appear 
brown. A further proof of the presence of biliary coloring 
matter will be found in a very dark sulphuric acid, reaction. 
The urine does not become garnet, but black. A similar 
reaction will only be observed when sugar or blood-coloring 
matter is present. Both are to be previously excluded. 

With liquor-potassa the earthy phosphates are precipitated 
of a brown color. 

Biliary coloring matter is found, in the urine in a variety 
of pathological changes in the liver, independently of jaun- 
dice, so that the latter can frequently be predicted several 
days before its appearance, by the urine. Furthermore, it 
is always found in phosphorous poisoning. 

V. Biliary Acids. 

These are rarely found in urine, and then only in small 
quantity. In jaundice, although the coloring matter of the 
bile may be present in great quantity, they are very rarely 
found. In diseases of the parenchyma of the liver, accom- 
panied by rapid destruction, they are undoubtedly found, 
but even then in small quantity. 

It must be accepted in such cases, that so great a quantity 



80 EXAMINATION OF THE URINE. 

of biliary acids is produced, that they can not undergo the 
normal changes in the blood, and are therefore found in the 
urine. 

Sometimes it is possible to demonstrate the biliary acids 
by means of Strassburger's method. Dissolve a small quan- 
tity of cane sugar in the urine that is to be tested, dip filter- 
ing paper into it and allow to dry. Going over this with a 
glass rod, dipped in sulphuric acid, free from nitric acid, will 
produce a purple-violet stripe (red or reddish-brown is not 
decisive). 

As a rule, however, it is necessary to separate the biliary 
acids, in a pure state, from a large quantity of urine, and 
then perform Pettenkofer's test. 

The separation is very laborious. Evaporate about 500 c. c. of 
urine in a water bath to dryness, and extract with ordinary alcohol. 
This solution, is again evaporated, and the residuum extracted with 
absolute alcohol. This alcohol is again dissipated and the solid treated 
with water, the solution precipitated with oxyacetate of lead, avoiding 
an excess, the precipitate collected, washed, and dried with filtering 
paper. Thereupon the salts, with lead as base and the biliary acids 
as acids, are extracted with boiling alcohol ; add sodium carbonate, 
then evaporate again, and finally extract the resulting sodium salt of 
the biliary acid with absolute alcohol. Now permit the alcohol to 
evaporate, and, with the concentrated watery solution, perform Pet- 
tenkofer's test. This is based upon the fact, that all watery solutions 
of the biliary acids, when mixed with a few drops of a concentrated 
solution of cane sugar and concentrated sulphuric acid, care being 
taken that they are not heated over 70 C. (158 F.), will produce a 
violet-purple color. It is best, therefore, as soon as the sulphuric acid 
is added, to put the test tube into cold water, otherwise the sugar 
will be charred by the sulphuric acid, producing a black color. 

A trace can be detected by Neubauer's modification; a few drops 
of the suspected fluid are evaporated to dryness on a porcelain dish, 



CARBONATE OF AMMONIUM. 8l 

upon the water bath. To this there is added a minute drop of a solu- 
tion of cane sugar, (1,00 gr. sugar in 500 c. c. water) and an equally 
large drop of concentrated sulphuric acid. Again, heat over the water 
bath until the violet color begins to appear at the circumference. 
Then take the dish from the water bath and the reaction will continue 
to become more marked. 

Many other substances, such as amyl alcohol, albumen, 
oleic acid, give the same reaction, but they can be differen- 
tiated by means of the spectroscope. 

Besides the substances treated of, there will occur in urine, allan- 
toine, especially after the administration of tannic acid ; then lactic, 
acetic and butyric acids in acid fermentation ; benzoic acid in putrid 
urine, as well as fats and soaps. 

VI. Carbonate of Ammonium. 

C0 3 (NHOi 

All the carbonate of ammonium that occurs in urine comes 
from urea. Urea, as has been stated before, is carbamide. 



CO 



|NH 2 
JNH 2 



By means of taking up water this is changed to ammo- 
nium carbonate. 

(NH 2 (0,NH* 

CO ] + 2H 2 = CO ] 

(NH 2 (o,nh* 

This change is the cause of development of ammonium 
in the decomposition of urine by putridity, which may occur 
in the bladder. The ferment is a body that adheres to the 
11 



52 EXAMINATION OF THE URINE. 

mucus of the bladder, and develops best during a catarrh. 
We therefore find, in nearly all diseases of the bladder the 
urine of alkaline reaction. The catarrhal secretion of the 
pelvis of the kidney does not seem to cause alkaline fermen- 
tation, certainly only after some time has elapsed; and we 
therefore find the urine in pyelitis nearly always of an acid 
reaction. If fresh, normal urine be mixed with the sedi- 
ment of urine from a pyelitis, and another specimen with 
that from cystitis, it will be found that the former will re- 
quire between 12 and 24 hours to show alkalinity, while the 
latter will become alkaline in a very short time (2 to 3 hours). 

Ammonium carbonate is also found in the second stage of 
processes with exudation, so-called absorption-urine, and is 
considered, here, a favorable symptom. This substance can 
be recognized by its odor. 

Urine containing it, moreover, is usually alkaline. But 
the alkaline reaction may depend upon a fixed alkali, as 
sodium carbonate, which has been taken internally. When- 
ever there is any doubt about the nature of the alkalinity, 
the following test can be used : 

Put into a small florence flask, 15 to 20 c. c. of the urine 
then close the flask with a cork, perforated, in order to allow 
a glass tube, of the thickness of a lead pencil, to pass through. 
Into this there is put a piece of red litmus paper that has 
been well moistened. Heat the flask carefully in a water 
bath; if ammonia is present, it will be carried off with the 
vapor of water arising from the urine and color the litmus 
paper blue. Care must be taken not to boil the urine, other- 
wise urea will be decomposed, giving rise to carbonate of 
ammonium. 

Ammonium carbonate is found : 



HYDROGEN SULPHIDE. 83 

i. Usually in the various forms of disease of the bladder. 
2. In the second stage of acute exudative processes. 

According to Heller, this salt is also found in troubles of the spinal 
cord and grave cases of typhus, even with acid reaction of the urine. 

VII. Hyrdogen Sulphide. 
SH 2 

Occasionally sulphuretted hydrogen is found in urine containing 
albumen, especially in troubles of the bladder where a great quantity 
of pus is produced. Here it is formed from the albumen, which de- 
composes while in the bladder. Although the odor is characteristic, yet 
it sometimes become necessary to prove its existence by a chemical re- 
action. In order to do this we use the same method employed for 
detecting the presence of ammonia, taking instead of the litmus paper 
a piece of filtering paper that has been dipped either into a lead or 
silver salt solution. The slightest amount of heat will cause the gas 
to escape and color the strip of paper brownish-black. 

Such urine is easily detected by the fact of its coloring silver cathe- 
ters black. 

Accidental Constituents. 

Under this heading we consider those substances that are exception- 
ally found or introduced into the organism, and then leave it by way 
of the urine. 

Many substances are not changed at all in the system, as ; most in- 
organic combinations, as well as many organic (succinic acid, chloro- 
form, quinia, carbolic acid, etc,). 

Of the heavy metals the following have been found: antimony, 
arsenic, copper, zinc, gold, silver, tin, lead, bismuth, and mercury: 
either as a result of introduction as medicine or on account of constant 
handling (painters, potters, etc.). 

Of the alkali salts nearly all pass into tne urine ; the carbonates, 
ammonium salts, chlorates, borates and silicates of the alkalies, ferro- 
and ferri-cyanide of potassium, cyanide of potassium, iodide of po- 
tassium, etc. Sulphide of potassium is found in the urine as sulphate. 
On the other hand calcium and magnesium salts are either not found 
at all, or in very small quantities only. 



84 EXAMINATION OF THE URINE. 

Mineral acids (sulphuric, nitric, phosphoric, etc.,) are found as the 
corresponding alkali-salts ; only free carbonic acid appears as a simple 
solution in the urine. 

Metallic bases can be detected either by electrolysis or by forming 
an ash, and then examining in the ordinary way. Arsenic is first pre- 
cipitated with sulphuretted hydrogen, and then can be easily detected 
by Marsh's method 

Many combinations, especially the organic, are changed in the organ- 
ism. The aromatic acids, for instance, are all excreted, as glycocol 
combinations so ; benzoic acid in the urine, as hippuric acid, salicylic 
acid (for the most part), as salicyluric acid. 

Carbonates of the alkalies are found : 

i. After the internal administration of the same. 

2. After the use of mineral waters. 

3. After eating much fruit, because the fruit acids are all con- 
verted into carbonic acid in the system. 

In these cases the reaction of the urine is alkaline. In order to 
prove the origin of this alkalinity, evaporate the urine to dryness, 
then add a little water and test with litmus paper. If we find an al- 
kaline reaction, it is proof positive that there have been permanent 
alkali salts present in the urine. 

Iodine is easily detected by adding to the suspected urine, sulphide 
of carbon, then fuming nitric acid and shaking (violet discoloration 
of the sulphide of carbon or chloroform). Starch solution can also 
be added, and then fuming nitric acid. A bluish discoloration indi- 
cates iodine. In Heller's test for albumen, iodine crystals are fre- 
quently deposited, 

Salicylic acid can be found by means of the violet color produced 
when cloride of iron is added. A similar reaction sometimes occurs 
in diabetic urine, even when salicylic acid is absent. 

D. — Sediments. 

Fermentation of Urine. 

Normal urine when voided is clear. After having re- 
mained in the vessel for some time, there is formed either at 



FERMENTATION OF URINE. 85 

the bottom of the vessel, or in the lower part of the urine, 
the so-called nubecula ; a cloud of mucus from the bladder, 
being very well marked when relieved by a black back- 
ground, or when there is contained in the mucus epithelium, 
in greater quantity than normal, or bacteria, or, suspended, 
traces of precipitated urates. 

In this condition an healthy urine, placed in a perfectly 
clean vessel, will keep for a long time; longer when the air 
is excluded — weeks, even months. 

Frequently, however, a change takes place, known as 
acid fermentation. 

In the urine there is found both the acid sodium phos- 
phate and urate of sodium. The phosphate acting upon the 
urate, by withdrawing some of the base from the urate, 
changes the latter to an acid salt, which, being insoluble, is 
precipitated in the form of yellow or reddish powder. This 
takes place especially at a low temperature. At high tem- 
peratures the process of decomposition goes on. From the 
urate all its base is withdrawn (sodium), and the uric acid 
being set free, and being comparatively insoluble, comes 
down in the form of a crystalline brick-dust red, or brown- 
ish-red, granular powder adhering to the walls of the vessel, 
floating on the surface of the fluid, or resting upon the bot- 
tom of the vessel. Sometimes these crystals of uric acid 
are mixed with the amorphous urates that have not as yet 
been decomposed — brick-dust sediment. 

During this process no free acid is produced, as can be 
proven by the appropriate tests. 

In the greater number of instances there is mixed with 
this sediment oxalate of lime, in small or large crystals. 
Some of the uric acid is transformed, in the body, into ox- 



86 EXAMINATION OF THE URINE. 

aluric acid ; this, when exposed to the air for some time, 
changes to oxalic acid, appearing in the sediment as oxalate 
of lime. 

This process, as will be seen, does not deserve the name, fermenta- 
tion. But in some cases true fermentation, with the formation of 
acetic acid, takes place. 

After this process has come to an end, there begins, 
sooner or later, another. The urine becomes paler, the 
crystals of uric acid have disappeared, acid reaction gives 
way to neutral, which finally changes to alkaline. The 
urine has an ammoniacal odor, becomes very cloudy, and 
has a white precipitate, made up of phosphates of the earthy 
alkalies. Under the microscope, this cloudiness will be seen 
to be made up not only, of suspended phosphates, but also 
of innumerable bacteria, at rest and also in motion. This 
process is actual or alkaline fermentation. The cause is the 
decomposition of the urea, it being acted upon by a pecu- 
liar ferment, discovered by Musculus. 

Musculus recommends paper, impregnated with the ferment, as a 
very delicate test for urea. The thick alkaline urine of cystitis is 
filtered. The paper used for filtering is washed with distilled water 
until it no longer reacts alkaline. It is then dried and colored with 
turmeric. Urea has no reaction upon turmeric, but when the ferment 
in the paper acts upon urea, this is decomposed and ammonium car- 
bonate thus generated colors the paper brown. 

The ammonia may unite with the uric acid to form urate 
of ammonia. When the formation of ammonia has reached 
its maximum, a part of it also unites with the phosphate of 
magnesia to form crystals of the triple phosphate. Phos- 
phate of calcium, which is soluble only in acid solutions, is 
precipitated, and we have the sediment of alkaline urine, 



SEDIMENTS. 87 

composed of amorphous masses of calcium phosphate, crys- 
tals of triple phosphate, and, in the beginning, of ammonium 
urate. 

Pus, blood or vessels already unclean with urine that has 
fermented, cause very rapid decomposition of the urine, it 
not being necessary for the urine to go through the so-called 
acid fermentation first. 

The process is accompanied by bacteria. Various fungi 
can be observed upon the surface of the urine, especially in 
warm weather. 

Classification of the Sediments. 

As long as these formed constituents of urine are mixed 
with the urine, they cause cloudiness ; as soon as they sink to 
the bottom, a sediment. Precipitation takes place variously ; 
quickly in thin urine containing heavy substances, such as 
uric acid or urates ; slowly in albuminous, dense urine contain- 
ing light substances, such as epithelium or hyaline casts. The 
constituents of the sediments are either formed inside or 
outside of the body. The elements are either organized (oc- 
curring both in acid and alkaline urine) or unorganized, 
partly amorphous, partly crystalline ; some found in acid, 
others in alkaline urine. Accordingly the sediments can be 
divided as follows : 

SEDIMENTS. 

I, of acid urine. II, of alkaline urine. 

A. — Non-Organized. 

(a) Amorphous. 

1. Urate of sodium and potassium, i. Calcium phosphate. 

2. Fats. 2. Calcium carbonate. 



38 EXAMINATION OF THE URINE. 

(b) Crystallized. 

i. Uric acid. i. Urate of ammonium. 

2. Oxalate of calcium. 2. Triple phosphate. 

3. Cystine. 3. Calcium phosphate. 

4. Tyrosine. 4. Magnesium phosphate. 

/ » v 

B. — Organized. 

1. Mucus and pus corpuscles. 

2. Blood corpuscles. 

3. Epithelium from the various 

parts of the urinary apparatus. 

4. Casts and coagula of fibrine. 

5. Spermatozoa. 

6. Cancer tissue. 

7. Entozoa. 

8. Fungi. 

In this order they will receive attention, 

Non -Organic Sediments. 
1. Urates. 

Uric acid is found in urine bound to sodium and potassium 
and forms salts of variable structure, so that by the with- 
drawal of base, more acid salts are produced, which become 
less soluble and, therefore, more ready to precipitate. 

Urates are more soluble in warm than in cold water ; the 
neutral salts are more soluble than the acid. From this fol- 
lows, that when stronger acids are added that displace part 
of the uric acid from its base, acid (less soluble) salts are 
produced from the neutral. These, in their turn, precipitate 
the more rapidly the colder the fluid is, and the smaller the 



URATES. 89 

quantity. The formation of the urates in the sediments is 
favored, then, by three following conditions : 

1. Moderate addition of acid (by means of great acidity 
the uric acid is precipitated) or the action of acid salts (so- 
called acid fermentation). 

2. Concentration of urine, either by means of the in- 
crease of uric acid or by the diminution of water. 

3. Cooling of the urine, which takes place naturally only 
after the urine has been voided or in the cadaver. 

The urates of the alkalies are an amorphous powder, 
which, on account of the coloring matter that comes down 
with it, appears yellowish, grayish brown, pink or brick- 
dust red. Under the microscope they appear as small 
granules, grouped like moss. If mixed with mucus the be- 
ginner may mistake the picture for that of a finely granular 
cast. They can be differentiated, however, by the absence 
of sharp contours, by the want of plasticity and, above all, 
by the reaction upon the addition of heat. 

The urates disappear when warmed. If any deposit is 
left, it will be seen to be pure uric acid. Upon the addition 
of an alkali and heat, even this disappears. 

This property of the urates permits a differentiation be- 
tween pus and the phosphates without the use of the micro- 
scope. Phosphates do not occur in urine of a decidedly 
acid reaction. In urine faintly acid, boiling would increase 
the deposit, especially if hydrate of potassium or sodium be 
added. 

If the urine contains pus, boiling alone would not make 
it clearer ; on the contrary, on account of the coagulation of 
the albumen, the deposit would become denser (alkalies, 
however, would probably prevent this coagulation). 

12 



9 o 



EXAMINATION OF THE URINE. 



Finally, the murexide test, performed with the dry sedi- 
ment, or the following beautiful micro-chemical test, would 
be decisive. Add to the urates that have been placed upon a 
slide a drop of hydrochloric acid ; after a time crystals of 
uric acid will be observed 

There are sometimes observed in urine having undergone acid fer- 
mentation, and beginning the alkaline, crystals of uric acid, partially 
dissolved, but having upon them prismatic crystals of urate of sodium. 

2. Urate of Ammonium. 

The acid urate of ammonium is the only urate that occurs 
in alkaline urine and is, therefore, found side by side with 
the amorphous phosphate of calcium and the triple phos- 
phate. 

Urate of ammonium forms brown balls, which are either 
developed singly, doubly, or in the form of a conglomerate 
with a kidney-shaped surface. The surface of these bodies 

|is either smooth or it 
lis covered with small 
■spikes, or these pro- 
cesses are long, even 
[divided, and then most 
[frequently curved, pro- 
ducing manifold forms 
[(Fig. 5). These forms 
[are so characteristic 
[that there can be no 
|doubt concerning the 
[nature of these crystals 
[when viewed under the 

Fig. 5.— Urate of Ammonium. * 




URIC AICD. 



91 



Other tests are the murexide, the formation of uric acid 
as described above, and, finally, the addition of caustic po- 
tassa, producing bubbles of liberated ammonium. 

3. Uric Acid. 

The occurrence of uric acid is due, partly, to the same 
causes that have been discussed under the head of urates. 
Normally the crystals of uric acid are found at the termina- 
tion of the so-called acid fermentation, in concentrated 
urine, especially in summer, where high temperature pre- 
vents the deposit of urates; then, in pathologically increased 
formation of uric acid, in which case neither water nor al- 
kalies suffice to keep the acid in solution. 

The primary form of| 
uric acid is that 0: 
rhombic plates with] 
rounded, blunt corners. 

This form is known' 
as the whetstone. The| 
crystals may be ver 
small or developed sin 
gly. Sometimes the; 
group about foreignj 
bodies, a s threads 
hairs, and then fori 
cast-like bodies. A 
other times the individ- 
ual crystals are highly 
developed and collect- 
ed together, appearing 
either fan-shaped or like the shingles upon a roof. Besides 




Uric Acid. 
Fig. 6. 
Rosette, b. Whetstone, c. Dumb-bell. 
Barrel-shaped, e. Lance-shaped. 



92 EXAMINATION OF THE URINE. 

the whetstone form are found barrel-shaped, and, in other 
cases, lance-shaped crystals, frequently united to form ros- 
ettes. The rough and lance-shape forms are of great practi- 
cal importance in that they always have some connection 
with the formation of calculi in the kidney. 

They occur only, in very acid urine. If this is counter- 
acted by the internal administration of fixed alkalies, then 
the form of the crystal changes to the normal, that of the 
whetstone. These forms are frequently found in the sedi- 
ment of pyelitis calculosa, and also accompany albuminuria 
(hyperemia of the kidneys) and hematuria. 

Intense desire to pass water, without albuminuria or 
pyelitis, is occasionally found in those patients whose urine 
contains these forms. 

In all cases the uric acid appears colored, faintly yellow, 
brownish-red or dark brown (on account of coloring matters 
that are brought down with it). 

The crystals are usually so well developed, that they ap- 
pear as glistening brick-dust red sand upon the bottom of 
the vessel, and may be diagnosticated with the naked eye. 

This sediment is dissolved in caustic alkalies when boiled, 
being partially changed to urates, partially to lower oxides. 
Finally, with the sediment, the murexide test is eminently 
characteristic. 

IV. Oxalate of Calcium. 

Oxalic acid has great affinity for calcium. As there is 
calcium in urine, the oxalic acid, formed in the kidney or 
in the urine, must be found in the latter in the form of ox- 
alate of lime. These crystals, as has been stated, frequently 



OXALATE OF CALCIUM. 



93 




appear, during acid fermentation, with uric acid. The shape 
of the oxalate of lime is very characteristic. They are flat 
octahedra, that refract| 
the light very much, 
sometimes appearing 
as small points, some- 
times as squares, whose 
corners are connected 
by diagonals, so that 
they appear like en- 
velopes (see Fig. 7). 
Besides this form, there 
is also that of the hour-| 
glass (dumb-bell). 
These crystals easily 
escape detection by 

the inexperienced, On Oxalate of Calcium and Cystine. 

aCCOUnt Of their low «, Cystine ; 3, Oxalate of Calcium. 

specific gravity, depositing very slowly. In order to detect 
them, it is necessary to allow the urine to stand for from 12 
— 24 hours. 

The characteristic form of these crystals prevents error in 
diagnosis. The only crystal that could be mistaken for 
them is that of the triple phosphate. But, in the first place, 
the crystals of oxalate of calcium are never as large as those 
of the triple phosphate — then the latter is always found in 
neutral or alkaline urine, the former always in acid, and 
finally acetic acid dissolves the latter and not the former. 

V. Cystine. 

Cystine forms regular hexagonal plates, differing in size, 



94 EXAMINATION OF THE URINE. 

arranged either singly, or in such a manner that one or more 
smaller crystals lie upon a larger one. Sometimes a large 
crystalline plate shows cleavage — that in its turn corresponds 
with the outline of a hexagon. Rarely twin-crystals are ob- 
served, and small, poorly-developed crystals are collected 
together in the form of irregular masses. (See Fig. 7, 6.) 

Sometimes the corners of the crystals are rounded off as 
if they had been melted off. The crystals are always color- 
less, and can only be mistaken for an exceedingly rare form 
of colorless uric acid. This could occur, possibly, if the 
dissolved cystine would be precipitated from the urine by 
acetic acid, as this would produce a similar, but more irreg- 
ular, deposit of uric acid in hexagonal plates. 

In order to be positive that the crystal under the micro- 
scope is cystine, allow a drop of ammonia to flow under the 
thin cover; the cystine will immediately disappear, while 
uric acid would remain, unless heated. As soon as the am- 
monia has evaporated the cystine again crystallizes. * This can 
be hastened when, to the ammoniacal solution there is added 
a drop of acetic acid. A second test consists in adding to 
the crystals of cystine a drop of hydrochloric or oxalic acid. 
Cystine is dissolved, while uric acid remains unchanged. It 
can not be mistaken for urates, on account of its form ; in 
addition, it is entirely insoluble in warm water. 

As cystine is soluble in ammonia, but not in carbonate of 
ammonia, alkaline fermentation will precipitate it like the 
earthy phosphates. From these it can be differentiated both 
by microscopic and chemical tests. 

The addition of acetic acid causing the earthy phosphates 
to dissolve, leaves the cystine unchanged. If, besides this, 
we boil, the greater part of the sediment may dissolve. The 



LEUCINE AND TYROSINE. 



95 



remnant being placed under the microscope may reveal hex- 
agonal plates, but these must be tested with ammonia and 
hydrochloric acid in order to separate the cystine from the 
uric acid that may be present. 

If cystine is dissolved in liquor potassa, heated, water 
and then a solution of nitro-prusside of sodium added, the 
mixture will turn violet (sulphur reaction). 

Urine in which cystine is detected is usually pale ; upon 
decomposition the odor of sulphur, besides that of ammonia, 
is developed, probably on account of the presence of sul- 
phur in cystine. The sediment is found in company with a 
cystine-calculus, and also alone. It appears white, grayish, 
mixed with triple phosphates and phosphate of calcium ; in 
acid urine with oxalate of lime. 

With us this sediment is very rare; it is said that cystinuria 
has been observed frequently in several members of the same 
family. 

Leucine and Tyrosine. 

(See Fig. 4, Abnormal Constituents). 

Leucine appears under the microscope in the form of 
spheres, of various sizes and more or less colored, that have 
the appearance of fat globules, They have sharp contours, 
and, with good light, show radii and delicate concentric lines. 

Tyrosine forms very fine, short needles, crossing each 
other, collected in groups, and these groups lying upon each 
other so as to form crosses. 

Sometimes this is found as a sediment, but more commonly 
we find globules of leucine mixed with it. Mistakes between 
leucine and fat globules can be prevented by ether, in which 



C)6 EXAMINATION OF THE URINE. 

fat is soluble, whilst leucine is insoluble. The crystals also 
dissolve in caustic potassa, but not in cold mineral acids. 

Tyrosine crystals, as such, can be detected in two ways : 
by Piria's and by Hoffman's test. The first method consists 
in putting a small quantity of sediment into a watch glass and 
moistening it with 2 or 3 drops of concentrated sulphuric 
acid. After twenty or thirty minutes have elapsed, water is 
added, then calcic carbonate until effervescence ceases, then 
the whole filtered. If, upon the addition of chloride of 
iron, (free from acid) a violet discoloration takes place, the 
sediment was tyrosine. 

The second method is simpler. Pour over the sediment 
water, and boil. To the boiling fluid a drop of a solution 
of nitrate of mercury is added. A red precipitate is formed, 
and the fluid has changed to pink or purple. 

Leucine and tyrosine are rarely found, and then, nearly 
always in acute yellow atrophy of the liver or in phosphorus 
poisoning. 

7. Fat. 

One must be very careful not to consider the film of fat 
that is found upon urine, as a product of the urinary organs. 
In every case we can satisfy ourselves that it is the result of 
the introduction of the catheter. We must be equally cau- 
tious in regard to finely divided drops under the microscope. 
They are usually the result of some foreign admixture, as 
oil, in the vessels in which the urine has been preserved; 
fat upon the slide, milk, etc. 

The statement that a high degree of fatty degeneration in 
the kidney will produce free fat globules in the urine, is one 
that we can not subscribe to, as a result of observation. A 



EARTHY PHOSPHATES. 97 

priori this is not probable, as that part of the kidney that is 
fatty does not excrete urine ; besides, requiring the assump- 
tion that the fat is separated from the kidney in the form of 
drops. That this idea is erroneous, can be shown at the 
post-mortem table. Emulsified fat is found in the chylous 
urine of the tropics, and the turbidity, inasmuch as it de- 
pends upon the fat, can readily be made to disappear by the 
addition of ether. It never forms a sediment, but, like 
cream, on account of its low specific gravity, it is found upon 
the surface of the urine. Under the microscope the fat 
shows globules with very sharp outlines: ether dissolves 
them. Cholesterin is found simultaneously with the fats ; 
rarely, however, and then in its crystalline form. It is re- 
cognized by its characteristic crystal form \ the transparent 
rhombic plates. 

Galacturia is met with very rarely in temperate climates. 

8. Earthy Phosphates. 

(a) Amorphous. 
In ammoniacal urine there is frequently found a layer of 
grayish- white sediment, which, by the beginner, may be 
mistaken for pus—this sediment consists of the precipitated 
earthy phosphates, u e., phosphates of calcium and mag- 
nesium. As has been stated, these salts are only dissolved 
in acid fluids ; they, therefore, must precipitate as soon as 
the urea is split up, causing alkalinity of the urine. Under 
the microscope the earthy phosphates appear like granules 
of varying size, not resembling the urates, however, in their 
configuration. The differentiation can be easily effected by 
means of chemical tests. The urates, with the exception of 
urate of ammonia, occur in acid urine, whilst the earthy 
i3 



gS EXAMINATION OF THE URINE. 

phosphates (excepting the crystallized phosphate of calcium) 
are only found in alkaline urine. The reaction with litmus, 
then, is sufficient to solve the question of urates or phos- 
phates. Heating causes the precipitate of urates to disap- 
pear, but increases that of the phosphates Upon adding 
caustic potassium or sodium the urates are dissolved ; the 
phosphates remain unchanged. 

The differentiation between pus and phosphates will be 
discussed further on. 

All causes for alkalinity of urine produce this sediment, 
which is greater or less according to the quantity of dis- 
solved earthy phosphates originally contained in the urine. 
Exceptionally, only, in diseases of the bladder and when 
great quantity of alkalies are taken internally, the urine is 
passed alkaline in reaction and then it is turbid, on account 
of the precipitation of the phosphates having taken place in 
the bladder; the rule is that the precipitation takes place 
after the urine has been passed. The so-called triple phos- 
phate, in its characteristic form, is always mixed with the 
earthy phosphate in the sediment. 

(b) Crystallized Phosphate of Calcium. 

This substance (P0 4 HCa-f 2H 2 0) is found in pale, faintly 
acid urine, having a tendency to alkaline fermentation, 
usually very rich in phosphate of calcium. This sediment 
seems to occur as a result of individual predisposition ; per- 
sons, otherwise perfectly healthy, are observed, whose urine 
in summer, always contains this sediment. 

Under the microscope either single, wedge-shaped crystals 
are found or different arrangements of this crystal ; several 
of them lying together, or having their apices directed to- 



PHOSPHATE OF MAGNESIUM. 99 

wards one point ; or in the form of rosettes, the bases forming 
the periphery of the rosette. The form of the crystal is so 
characteristic that error is hardly possible. The triple phos- 
phate never forms rosettes, and uric acid can always be dis- 
tinguished by its color and insolubility in acetic acid. 

IX. Phosphate of Magnesium. 

In neutral or faintly alkaline urine, especially after the in- 
ternal administration of carbonates, or mineral waters con- 
taining these, there are occasionally observed long quadri- 
lateral plates, whose ends are rounded — basic phosphate of 
magnesium (probably Mg 3 (P0 4 ) 2 +i7H 2 0). If a drop of a 
solution of carbonate of ammonia (in 5 parts of water) is 
added, these plates become opaque, rough, and their corners 
fade. Phosphate of calcium is affected much more slowly, 
and does not become opaque, and the triple phosphate shows 
no change whatsoever with this test. 

This sediment is very rare, and can only develop in urine that is 
very much concentrated and, originally, of neutral or alkaline reaction' 
If alkaline fermentation causes the alkalinity, then no magnesium 
phosphate can be formed, the ammonium magnesium phosphate 
always being the result. 



IOO 



EXAMINATION OF THE URINE. 



X. Triple Phosphate. 

This substance is im- 
mediately recognized 
by its large, transpar- 
ent crystals, that refract 
the light very much, 
having well-developed 
surfaces and angles. 
Among the manifold 
combinations of the 
rhombic form, fre- 
quently hemimorpho- 
his, the coffin lid, is 
best known. Mistake 
Fig. 8. can be conceived only 

Triple Phosphate. between common salt, 

oxalate of lime, and this crystal. Common salt, however, 
is never found in natural urine, only in urine concentrated 
by evaporation. The reaction with acetic acid prevents any 
error of diagnosis regarding the larger crystals of oxalate of 
lime, the triple phosphate always disappearing upon the ad- 
dition of this reagent. The conditions producing the ap- 
pearance of the triple phosphate are the same as those dis- 
cussed under the head of earthy phosphates. 




XI. Carbonate of Calcium. 

Urine of most of the herbivora when voided is turbid, de- 
pending upon the separation of carbonate of calcium. Ex- 
ceptionally, only, these conditions are found in the human 
being, the sediment forming some time after the urine has 



MUCUS. 101 

been passed. The causes for this phenomenon are obscure. 
The sediment, probably, never occurs alone, but mixed 
with earthy phosphates, and exceptionally forms dumb-bell 
crystals; most commonly it is coarsely granular or a fine 
powder. It is recognized by its effervescence and solubility 
upon the addition of mineral acids. This can be observed 
under the microscope. If a drop of hydrochloric acid is 
allowed to flow under the covering glass, small bubbles of 
gas (carbonic acid gas) will be seen to escape. This is never 
observed when earthy phosphates only are present. Before 
making the test, the sediment must be carefully washed upon 
a filter, to remove the carbonate of ammonium, which would 
show the same reaction as the substance tested for. 

Organized Sediments, 
i. Mucus. 

Great quantities of mucus may be present in the urine 
and not be easily detected, on account of the slight differ- 
ence that exists between the index of refraction of urine and 
mucus. It is only when urine has been allowed to stand 
for some time ; when an abnormally great quantity of epithe- 
lium is present, or as a result of great and rapid develop- 
ment of bacteria, that mucus can be observed in the form 
of the nubecula already described. 

In all cases in which these causes are not present, it becomes 
necessary to color the urine. 

If albumen is not present, the mucus can be precipitated 
by alcohol to which tincture of iodine has been added; or 
acetic acid to which a solution of iodine in iodide of potas- 
sium has been added, is used. Acetic acid produces tur- 



102 EXAMINATION OF THE URINE. 

bidity in solutions of mucin which is not dissolved by excess 
of acid; disappearing, however, upon the addition of a few 
drops of hydrochloric acid. 

If the turbidity disappears upon heating, then it was not 
caused by mucus but by the urates. Mucus does not show 
a characteristic picture under the microscope ; but we find 
small bodies suspended in the mucus; crystals of oxalate of 
lime and uric acid, mucus corpuscles, (young cells) or epi- 
thelial cells of the bladder. 

Mucus coagulated by acetic acid appears under the micro- 
scope in the form of a finely granular, striped mass, some- 
times resembling casts. 

In women the nubecula is usually greater than in men, be- 
cause there is always present in the urine more or less 
mucus from the vagina — especially is this the case in leu- 
corrhcea. As mucin does not dissolve in water, but swells 
up, it can be separated from urine by means of filtration. 
The mucus remains upon the filter, and, when it dries, 
appears like a varnish. Urine containing much mucus is 
not easily filtered, because the substance fills up the pores of 
the paper. 

2. Epithelium. 

In treating of mucus we saw that there are suspended in 
it young cells that were called mucus corpuscles. But cells 
of other description that formerly lined the urinary appar- 
atus or formed part of the glanduar substance of the kidneys, 
also appear in urine. 

Their forms in the urine are not as manifold as when 
taken directly from the organs in the cadaver, depending 
upon the fact that the urine alters the shape of the cells. 



EPITHELIUM. 



103 



The forms of the cells may be divided into three classes : 
. 1. Round cells. 

2. Conical cells and cells with processes. 

3. Flat cells. 



come 



uriniferous tubules 



1. The round cells 
and the deeper layers 
of the membrane lining 
the pelvis of the kid- 
ney. In their original 
form they are more or 
less flattened, depend- 
ing upon their arrange- 
ment. Influenced by 
the urine they swell up 
and represent spheres. 
They have a well-de- 
veloped nucleus, and 
by it are differentiated 
from pus. Pus cells 

* Fig. 9. — a, Epithelia from male urethra; b, 

are granular, and Only from the vagina ; c, from the prostate gland ; d, 
. . from Cowper's glands ; e, from Littre's glands \ f, 

Upon the addition Of from the female urethra; g, from the bladder. 

acetic acid show a nucleus. Epithelial cells have but one 
nucleus, pus cells two or three, rarely more ; finally epithe- 
lial cells are larger. 

In acid urine epithelial cells are preserved for some time, 
but when the urine becomes neutral or alkaline they appear 
larger, nearly hyaline, in that the granular protoplasm col- 
lects around the excentric nucleus, and, finally, are com- 
pletely dissolved. The epithelium of the male urethra can not 
easily be distinguished from that of the kidney by means of 
the microscope. The chemical reaction of the urine must 
here be taken into consideration. If the urine contains 




104 EXAMINATION OF THE URINE. 

albumen the cells originate in desquamation in the uriniferous 
tubules ; this not being present the cells are, in all probability, 
from the urethra. 

The cells from the prostate, Cowper's and Littre's glands 
are like those of the urethra and can not be distinguished 
from them by means of the microscope ; in all probability 
they rarely occur in the urine. Fused with mucus and pus 
they form the shreds found in gonorrhoea. 

The conical cells and cells with processes, in the majority 
of cases, come from the pelvis of the kidney ; very fine and 
delicate cylindrical cells may be from the accessory organs 
of the male urinary apparatus, but these are quite rare. 
They are commonly twice as long as they are broad and 
tapering towards one extremity. The second variety may 
have either one or two processes (unipolar and bipolar cells). 
The occurrence of these must not be considered as a symp- 
tom of neoplasmata, as is laid down in many of the older 
text books. 

3. Flat cells either originate in the bladder or in the 
vagina. 

As the name indicates their form is flattened. Usually 
they are irregular, polygonal, having rounded edges and a 
dark, sharply-defined nucleus that is nearly central. The 
latter protrudes somewhat and a cell of this sort when seen 
in profile appears thicker in the middle, like a spindle- 
shaped cell. 

It is only with difficulty that epithelium of the bladder 
can always be distinguished from epithelium of the vagina. 
The cells from the bladder are more delicate, and usually 
are found singly ; those from the vagina are tougher — some 
times seem like scales; nearly always in larger or smaller 



PUS CORPUSCLES. I05 

flakes, above all in layers, a thing that can not occur with 
the epithelium of the bladder. 

The yellow discoloration of the nuclei of various epithelial 
cells in jaundice is of interest. If a drop of fuming nitric 
acid is allowed to flow slowly under the thin covering glass. 
the well-known play of colors of Gmelin's test (green, blue, 
violet,) is produced (Ultzmann). 

III. Pus Corpuscles. 

Pus corpuscles in urine have the same microscopical char- 
acteristics that are possessed by those from a suppurating 
wound. They are round cells, twice as large as red corpus- 
cles of the blood, and have a granular exterior, which covers 
over the nuclei. These will appear immediately, however, 
upon the addition of acetic acid. The granular appearance 
disappears, the corpuscles swell, and the multiple central 
nuclei become visible. One rarer form differs from this 
common form ; the corpuscles are not round, but have many 
processes, so that they resemble the amceba. 

Especial changes are undergone by pus corpuscles in 
alkaline urine, due to the action of carbonate of ammo- 
nium. They are fused, melted together, and the microscope 
then reveals an homogeneous mass with nuclei. Such pus 
forms an adherent, vitreous mass, which can only be poured 
out as a whole, somewhat like the white of egg. 

Especial attention must be called to the fact that these 
masses are neither albumen nor mucus. The former nrcer 
forms a sediment, and the latter never forms adherent masses. 
If pus is present, there must also be present pus-serum, and 
therefore albumen. In every case, then, the albumen test 
discovers albumen, which is not the case with mucus. 
14 



106 EXAMINATION OF THE URINE. 

The number of pus corpuscles varies very much. In 
some urine so few are found that they are not detected by 
the naked eye ; in others they are so numerous that a yel- 
lowish or grayish-white precipitate of the height of a finger 
is found. 

In acid urine it is possible to confound the urates with 
pus ; in alkaline, the phosphates. The former have already 
been differentiated in another place. The phospates disap- 
pear upon the addition of a few drops of acetic acid, the pus 
does not. 

But we have a positive test, without using the micro- 
scope, for pus — Donne's. 

Pour the urine from the sediment, add to the latter a piece 
of caustic potassa or soda and stir with a glass rod. If the 
sediment consists of pus it will lose its white color, will be- 
come green and vitreous, denser, and finally be reduced to an 
adherent mass, i. e. y it assumes the appearance of pus in am- 
moniacal urine. As there exists in urine no other body 
that causes this reaction, the test is a positive one. Only 
when the quantity is small we will not obtain a mass — the 
sediment, however, disappears and in its stead we have a 
mucilaginous fluid. 

Not infrequently we find in the sediment pus corpuscles 
that have been destroyed (detritus), blood corpuscles, epi- 
thelium, etc. 

4. Blood Corpuscles. 

The presence of blood corpuscles, even in small numbers, 
can be detected without difficulty by the microscope. When 
the urine appears of a brownish-red tint, suspicious of blood- 
coloring matter or blood corpuscles, it must be allowed to 



BLOOD CORPUSCLES. I07 

stand for some time in order to permit the light corpuscles 
to come down as a beautiful red sediment (frequently only a 
trace). 

In acid urine they retain their characteristic shape for a 
long time. They represent small discs that possess shading 
corresponding to a central depression. If seen in profile 
they appear bi-concave.a 
They are always sep- 
arate (except in excesi 
ive hemorrhage from! 
the bladder), when they 
are arranged in money-l 
roll order and appear 
reddish, slightly tinted] 
with green. 

This original form is] 
subjected to manyi 
changes, according to 
the fluid in which the! 
blood corpuscles are^^^^^^^^^JJ^J" 

found. If the Urine is Blood Corpuscles. 

rv>Ti^l-» A\^l^^^A <*o T° the right and above — red corpuscles acted 
Very mUCn ailUtea, eS- upon by diluted urine ; to the left, acted upon by 
~«~:„1'U, «,1,^^ "k~~:~ salts; in the middle, the crenate form; and below, 

pecially when begin- the n ' r m ai. 

ning to be alkaline, they swell up. The depression disap- 
pears, the blood corpuscle becomes spherical and seems 
smaller than before. The shading in the centre disappears 
with the depression, but appears at the periphery, by which 
it is recognized as a sphere. 

When acted upon further, the corpuscle becomes less 
distinct, appears as a small bubble, then as a mere shadow, 
and finally disappears altogether. 

By the action of salts the blood corpuscles become smaller 




108 EXAMINATION OF THE URINE. 

and crenate. The latter form is sometimes observed in 
urine, by the side of the normal. They seem to be produced 
by small crystals whose corners lift up the surface of the 
blood corpuscle. Sometimes the corpuscles are not round, 
but oval, of various sizes, and twisted into the form of a cup. 

In haematuria, accompanying parenchymatous diseases of 
the kidney and bladder, we find, nearly constantly, spher- 
ical corpuscles of varying size. Very small, even dust-form 
corpuscles (mycrocytes), are found in these cases by the 
side of normal and large forms (macrocytes). 

When blood corpuscles are present, even in very small 
quantity, albumen can always be detected. 

If the corpuscles are dissolved by alkaline urine, the blood 
coloring matter (haemo- and methaemo-globine) can be de- 
tected according to methods described elsewhere. 

The etiology of bloody urine will be discussed in Chapter 
VIII. 

V. Casts. 

Of the greatest importance for the diagnosis of kidney 
disease are those structures, disclosing their origin by their 
form — the uriniferous tubules, and called casts. 

In searching for these structures in urine, the greatest 
caution is necessary, so that they are not overlooked. On 
account of their low specific gravity they remain suspended 
in the urine for a long time, in addition to which they 
always appear in urine containing albumen, in which every- 
thing suspended will settle slowly. 

The first condition is that the urine be allowed to stand for 
several hours, then carefully decanted and the remainder 
poured into a wine-glass and allowed to stand for one or two 



CASTS. 



IO9 



hours. The last drops of the sediment are put under the 
microscope for examination. One must not be satisfied with 
one preparation, as it is frequently necessary to examine 
several, otherwise the casts elude discovery. On the other 
hand, one must guard against mistaking other structures 
for casts. Beginners are apt to consider every cylindrical 
arrangement of phosphates or urates, especially when de- 
posited in mucus, as finely granular casts. 

Casts are usually accompanied by albuminuria. As well 
as there occur cases in which albumen exists without the 
presence of casts, equally well casts are found without al- 
bumen. Examples of the first anomaly are found in albu- 
minuria of interstitial nephritis, in the amyloid and the hy- 
peraemic kidney; example of the latter is any serious inflam- 
matory process in which the casts may precede the presence 
of albumen by from 1 2 to 24 hours. 

Amongst the manyg 
varieties of casts, thej 
following can be con- 
sidered the typical! 
forms: 1, the coarse! 
fibrine cast ; 2, the fine 
ly granular cast ; 3, thej 
hyaline cast; 4, the| 
epithelial cast; 5, the 
so-called uric acid cast; 
6, casts of bacteria andj 
cocci. 
1. The Coarse, Fibri\ 
Casts are roller-like, 1 „. 

9 Fig. iz.— Casts. 

COarse, frequently COrk- a, Finely granular; 3, waxyi c, blood-casts. 

screw coagula, with sharp outlines, and of yellowish or 




IIO EXAMINATION OF THE URINE. 

brownish-yellow color. Their diameter, greater than that 
of any cast, indicates that they are formed in the lowest part 
of the collecting tubule, near its opening into the papilla. 
Not infrequently epithelial cells adhere to them. Bloody 
casts may be considered as a variety of this form, consisting 
of coagulated blood from rupture of the glomeruli. They 
are always dark brown, and, in some cases, seem to consist 
entirely of blood corpuscles ; in other cases, we observe in 
one part of the cast coagulated fibrine only, and in the other 
only blood corpuscles. This form is always accompanied 
by blood corpuscles in the sediment. (See Fig. n, c.) 

2. The Finely Granular Casts (Fig. 1 1, a) are more delicate 
than those described above. They, apparently, are derived 
from the smaller tubules. They possess distinct contours, and, 
as their name implies, are finely granular throughout their 
whole extent. They are straight and rounded off like a 
finger either at one or both ends. They are of the same 
diameter throughout, narrowed at one point, or tapering at 
one end. In their granular structure, also, many modifica- 
tions are observed. In places they are coarsely granular, in 
others this appearance is nearly lost so that they approach 
the hyaline casts, to be described presently (half-granular 
casts). Sometimes distinct fat globules are present. The 
addition of acetic acid, in some cases, causes a decided 
clearing up; in others, no effect at all is produced. The 
color of these casts is a faint grayish yellow. 

Both forms retain their shape for a long time in acid urine, 
losing it gradually in alkaline urine. 

3. The Hyaline Cast (Fig. 12, b) is partly of the size of the 
granular casts partly, much smaller. They are either perfectly 
straight, frequently of considerable length, or curved. Whilst 



CASTS, 



III 




some produce the impression of a solid, others seem like tubes 
with very delicate walls; the one being decidedly cylindrical, 
the other like tape.! 
Not infrequently casts! 
are found that are spi-l 
ral, with one or morel 
turns. With the larger! 
ones, distinct outlines! 
can be observed; the! 
smaller appear like! 
shadows under the mi-l 
croscope, and can bel 
separated from theirl 
surroundings only with! 
difficulty. In such! 
cases it becomes ad- 
visable,^ order to bring 
out the outlines, to add 
a few drops of a solution of iodine in iodide of potassium or 
aniline violet. By means of this, the casts appear yellowish 
(or bluish-violet), and can easily be distinguished. They 
show no signs of granulation, but are peHucid and hyaline. 
On account of the size of those formed like tapes, we are 
justified in thinking that they come from the finest ramifica- 
tions of the uriniferous tubules, perhaps from the ascending 
limb of Henle's loop. Hyaline casts disappear very rapidly 
in alkaline urine. 

4. Waxy Casts (Fig. 11, 6), nearly always, are of the same 
breadth as the granular, perfectly vitreous, refracting light so 
much that their outlines stand out somewhat like the crystals 
of the triple phosphate, or similar clear crystals. They are 



Fig. 12.— Casts. 
Uric-acid casts; b, hyaline; c> epithelial cast. 



112 EXAMINATION OF THE URINE. 

straight, with sharply-broken ends or tortuous. Their sur- 
face is sometimes wavy, as if the cast were made up of 
masses of colloid substance that have become fused. In 
places there is noticed distinct cleavage, that produces the 
impression, as if a gelatinous mass had been compressed 
and given way. They show the amyloid reaction, and pos- 
sess greater resistance than other casts. This form is very 
rare, and, up to the present, only found in amyloid degener- 
ation and tuberculosis of the kidney. 

5. Epithelial Tubes and Casts (Fig. 12, c). There are pro- 
cesses in which the epithelial lining, in toto, is stripped from 
the membrana propria of the tubules, and on account of the 
vis a tergo of the urine, or a fluid exudation is washed from the 
tubules. These structures, made up of epithelial cells, and 
hollow, are called tubes. In the same sediment, or without 
the presence of these tubes, are found casts that are cov- 
ered with epithelial cells, as if with the finger of a glove. 
The cells always are cloudy, somewhat swollen, and rarely 
possess sharply-defined outlines. Frequently, they are so 
much enlarged that they resemble more a finely-granular 
mass, which, however, can be seen to be made up of cells 
by the nuclei that are present at regular intervals. 

Amongst epithelial casts are found such, in which the epi- 
thelial layer is wanting in places where the congealed exu- 
dation can be observed. In others the central exudation 
protrudes beyond the epithelium. 

6. Uric Acid Casts (Fig. 12, a) differ very much from the 
preceding in regard to their structure, and can only be classed 
with them on account of their common origin. These casts are 
found most commonly during the first days of life in those 
children that suffer from uric acid infraction. There can be 



CASTS. II3 

observed, in the urine, as well as in the liver of such pa- 
tients, small, red bodies, which, under the microscope, show 
a cylindrical structure. They are made up of balls of urates 
not as we would infer from their name of pure uric acid. 
They are brownish-red, show a decidedly granular structure, 
and vary very much in regard to size. Treated with caustic 
potassa, ammonia escapes, and the casts disappear. There 
are also found parts of casts. 

7. Casts made up of Bacteria and Cocci only occur in 
suppurating interstitial nephritis, and only then, when the 
disease is complicated with emboli of bacteria in the urinif- 
erous tubules (Nephritis Parasitica — Klebs). 

These casts are found of the shape and size of the large 
fibrine casts. They come from the collecting tubules, and 
sometimes are divided dichotomously, showing that they 
originate where two large tubes unite. They are made up 
entirely of cocci and bacteria. On account of the bacteria 
being at perfect rest, these casts resemble the coarse granu- 
lar ; but high powers make mistake impossible. 

Amongst the forms already described, several will not be 
found that are mentioned in text-books; because we have not 
observed them, and therefore must conclude that they are 
exceedingly rare. We refer here to casts of pus cells, not 
to be mistaken for those short plugs closing up the mouths 
of the tubules at the papilla and characteristic for chronic 
pyelitis ; furthermore, casts made up of oxalate of calcium, 
and casts having uric acid imbedded in them. It is very 
common to find casts having oxalate of calcium or uric acid 
adhering to them, but these are not imbedded in the cast, 
and therefore have been accidentally formed outside of the 
uriniferous tubule. 
IS 



114 EXAMINATION OF THE URINE. 

IX.* Fungi. 

In urine are found forms of fungi partially developing ; 
some of these are frequently found, others are accidental ad- 
mixtures. 

Those forms that are most commonly seen are : i. Bac- 
teria. 2. The Yeast Fungus. 3. Sarcinae. 4. Oidium lac- 
tis. 5. Spores and fragments of penicillium glaucum. 

1. Bacteria, principally found in alkaline urine ; by dif- 
ferent authors, have been classified as vegetables or animals, 
and therefore been differently named, as vibriones, monas 
crepusculum, microzyma, etc. It seems settled now that 
they are to be considered as fungi belonging to Nageli's 
schyzomycetes. They differ very much in appearance, and, 
practically, it is well to give to the different forms different 
names, according to A. Vogel, always bearing in mind, 
however, that it is the same fungus. 

(a) T7ie Monad, Round, puncti-form bacteria, either at 
rest or vibrating. Care must be taken not to take earthy 
phosphates having molecular motion for these fungi. Gran- 
ules of a dead body have motion, but do not change their 
place in the field like the bacteria. 

(b) The Rod, Very small rods, hardly as long as the di- 
ameter of a red blood corpuscle, whose thickness is to 
small for measurement. Both extremities are somewhat di- 
lated. They are at rest or in motion. 

(c) The Leptothrix, or Chain Form, are long chains, fre- 
quently extending over the whole field, and can be distin- 
guished from the vibriones by their length. With high 
powers their structure can be observed. They rarely move, 
and then very slowly. 

(d) The Vibrio, originating in the former. Several rod- 
bacteria adhere to each other, and move about either in 



FUNGI, 115 

spirals or in that the members at the ends vibrate like the 
tail of a fish. Frequently they move with great rapidity. 

(e) The Zooglea Form. Masses of punctiform bacteria, 
held together by a gelatinous mass, and looking like a mass 
of earthy phosphates imbedded in mucus. 

All these forms can| 
be observed in one! 
urine, even in one| 
preparation. 

2. The Yeast FunA 
gus — SaccharomycesX 
Urinae. Single, vesic-j 
ular cells of the size of 
red corpuscles, some-I 
what oval. Commonly! 
arranged in a beaded! 
form, or as one large! 
cell having several! 
smaller ones resting ™" Fig. 13.— Fungi. 

Upon it. Their num- «, Micrococci and vibriones ; b, Sarcinae ; c> 
. Saccharomyces urinae; d, Yeast-fungus ; e. PcnicH- 

ber IS USUally much Hum glaucum. 

smaller than that of bacteria ; they are found principally 
in acid urine, and in warm weather this fungus is very like 
the yeast fungus of beer (saccharomyces cerevisiae), without 
being identical with it. In the urine of diabetes the same 
form, better developed, is found. 

3. Sarcina. Resembles the sarcina ventriculi, but is 
much smaller. They are arranged in groups of 2, 4, 8, 
etc., cells, and where they are collected in the form of cubes, 
resemble very much, bales of goods. 

Urine in which this form is found is usually alkaline, and 
we therefore also find phosphate of calcium and the triple 




Il6 EXAMINATION OF THE URINE. 

phosphate. They are usually observed for weeks, even 
months, in the urine of the same patient. 

4. Oidium Lactis. Long cells, to be recognized by the 
nuclei, which are in rows, at regular intervals from each 
other. Not infrequent in fermenting diabetic urine. Be- 
sides those mentioned, we find in urine sporules of 

5. Penicilliutn Glaucum y in partial division. Sometimes 
they are mixed with fine urates, so that they appear like fur 
and brownish-red ; or their development has progressed, and 
we find a network of fine thallus threads. 

The seeds for the development of all these forms, as a 
rule, are mixed with the urine outside of the bladder. But 
this rule has exceptions. The sarcina is voided with the 
urine ; this is sometimes the case with bacteria, but the cause 
is to be found in unclean catheters and sounds. We have 
rarely met with cases in which an instrument had not been 
introduced into the urethra or bladder. Whether these 
structures play a role in fermentation and the reaction of 
urine, is very doubtful. The small chains appear not only 
in alkaline urine, but everywhere where albuminous sub- 
stances undergo decomposition. We find them, therefore, 
in secretions from a variety of ulcers, in bad pus, in pass- 
ages from cholera patients, etc. 

Formerly a membrane, named kyesteine, made up of 
fungi, phosphate of calcium, triple phosphates, and some- 
times animal organisms, was held to be characteristic of the 
urine of pregnant women. This is also found upon the 
urine of males, and therefore is of no value as a sign of preg- 
nancy. 

VI. Spermatozoa. 

Spermatozoa, when viewed with high power, appear as 
small, spherical structures, with a hair-like tail. In urine 



CANCER. 



II 7 



they are rarely found in motion. Urine containing sperm 
frequently shows small, cloud-like bodies, which, under the 
microscope, are seen to consist of spermatozoa imbedded in 
a finely granular mass. The spermatozoa are very light, and 
therefore require from 6 — 12 hours before they are found in 
the sediment. They may be found several days after the 
urine has been passed, and under the following conditions : 

1. After coitus, nocturnal emissions, etc., when semen 
has remained in the urethra and been washed out by the urine. 

2. In spermatorrhoea ; in grave attacks of typhus, invol- 
untary passages of semen have also been observed. 

In the urine of women, spermatozoa are found after 
coitus, and may be of medico-legal importance. 
VII. Parts of Cancer. 

Two forms of cancer parts are observed, both very rarely, 
however, (a) Single cancer cells, (b) Pieces of cancer tissue, 
(a) The cells vary, frequently unusually large, caudate cells, 
with multiple nuclei.! 
Sometimes so-calledl 
nests are observed. We| 
must be cautious not 
to mistake caudate! 
cells from the kidney! 
(pelvis) for cancer cells.] 
The cells correspond! 
with the epithelial cov-T 
ering of the cancer! 
granulations, and com-T 
monly originate in the! 
bladder. We arejusti-T 
fied only in making a" 

probable diagnosis Fi * 1 <- Canc « Tissue » nd Cel,s - 
when these peculiar cells are present in great quantity. 




Il8 EXAMINATION OF THE URINE. 

(b) The Stroma of the Papillary Cancer occurs in various 
forms in the sediment. Either it is well preserved, and then 
the diagnosis is easy, or it is necrotic, and then the di- 
agnosis becomes exceedingly difficult. When well-preserved, 
we see a dentritic vegetation, covered by a single layer of 
epithelial cells, and consisting of an ecstatic blood-vessel. 
This is a rare picture. More commonly we find the dead, 
modified papillae, and their diagnosis is exceedingly difficult. 
The dentritic form can no longer be verified, the epithelial 
covering has been destroyed, and the papilla itself infiltrated 
with pus corpuscles. In this formless mass, however, occa- 
sionally structures are found that make the diagnosis much 
easier. They are : 

When treating the necrotic tissue with glycerine, beautiful 
crystals of haematoidine. They appear of a yellowish- 
brown color, either in the form of rhombs or bundles. This 
tissue, treated with fuming nitric acid, gives, under the mi- 
croscope, the characteristic reaction for bile coloring matter. 
Haematoidine is only found in old extravasations of blood ; 
if we discover it imbedded in necrotic tissue, the diagnosis 
of old hemorrhage is positive, and this has only been found 
in papillary tumors. This form is found only in acid urine. 

Another form of crystal, which we have found only in ne- 
crotic cancer tissue, and only in acid urine, is a rare form of 
oxalate of calcium ; dumb-bells crossing each other, some- 
times spherical. 

Sometimes we find with low powers flakes of dense, dark, 
tubular, branched structures. These are the minute blood- 
vessels. 

If the urine is highly alkaline, the papillae are covered 



ENTOZOA. 119 

with phosphates, and so much changed that a diagnosis is 
next to impossible. One examination does not suffice for a 
recognition of this disease. 

VIII. Entozoa. 

As yet we have never had occasion to see parts of en- 
tozoa in the urine. According to other authors the hook- 
lets of echinococci are said to occur in the sediment. But 
we have observed both hooklets, and also a piece of an 
echinococcus-sac with the animals, in fluid drawn from a 
tumor of the kidney, and it is possible that when this tumor 
breaks into the pelvis of the kidney, hooklets would be found 
in the urine. 

In the tropics haematuria, produced by entozoa, is fre- 
quently observed. The entozoa, most important in this re- 
spect, are the distoma haematobium or the bilharzia haema- 
tobia. They probably migrate from the intestine into the 
venous plexus of the prostate gland and there lay their 
eggs. These are of oval form, having at one end a sting- 
like process and plug up the smaller vessels in the bladder. 
There is produced catarrh of the bladder, with hemorrhage, 
and the eggs are discharged with the urine. 

It is hardly worth mentioning that a great many acci- 
dental impurities, having no relation to the urinary appar- 
atus, may be found in the urine. 

Pieces of feathers, of wood-cells, of plant parenchyma 
(tobacco leaves, for instance), dust, very fine fibres of cotton, 
silk, etc. Neither is it necessary to mention that care must 
be taken not to mistake substances upon the slide or their 
cover, or air bubbles, for sediments. 



120 EXAMINATION OF THE URINE. 

Addendum. 
Concretions. 

By concretions we mean hard, stony bodies, made up 
either of normal or abnormal constituents of urine. They 
vary very much in size. We find them as large or larger 
than a fist, and then others that can only be detected by 
means of the microscope. 

Every concretion, whether large or small, must show a 
deposit of molecules in layers and must be more or less 
rounded. The only exception is the cystine calculus, which 
upon section shows a crystalline structure. 

If we wish to judge, then, upon this point, we must take 
either a lens or a microscope. 

We frequently find concretions of uric acid that, with 
the naked eye, might be mistaken for a conglomerate of 
uric acid crystals (rosette). Also concretions of calcic car- 
bonate are found which show the arrangement in layers only 
when a power of ioo or 200 diameters is used. 

The small concretions usually come from the kidney, the 
larger ones from the bladder. 

Calculi are either made up solely of one constituent or of 
several, arranged in layers. Thus uric acid calculi usually 
consist throughout of uric acid, or its salts ; cystine calculi 
of cystine ; while the oxalates frequently have a nucleus of 
uric acid and an outer layer of phosphates, and the phos- 
phates a nucleus of uric acid. 

It is immaterial whether one or more constituents are used 
for the formation of the calculus ; we are always in a posi- 
tion to distinguish the nucleus. 



CONCRETIONS. 121 

In order to examine the structure of the calculus it is 
necessary to cut it by means of a fine watchmaker's saw. 
The innermost layer is the nucleus, which varies in size from a 
millet seed to that of a pea or over, and shows to greatest 
advantage when surrounded by a layer of a different struc- 
ture from its own. 

The nucleus is the most important part of the calculus, as 
it alone gives definite knowledge regarding the genesis of 
the stone. If we find an uric acid nucleus in a phosphatic 
calculus, we will know that calculus formation was caused 
by uric acid; if we find a foreign body, as a piece of cathe- 
ter or bougie, we may know that this was the primary cause. 

From a surgical stand-point calculi are divided according 
to their principal constituent : thus calculi of urates, oxalates, 
phosphates, and cystine. This division is of great practical 
importance, for, if a surgeon states that a calculus is phos- 
phatic, he, at the same time, implies that it is soft; if oxalate 
or urate, that it is hard. 

But as these are calculi, made up of three or more differ- 
ent layers, it is better to divide all concretions by taking for 
a basis their nuclei, and in this way form two groups. 

One group contains all those calculi whose nuclei are 
formed by the sediments of acid urine ; the second those 
whose nuclei are either foreign bodies, coagula of blood, 
or constituents of alkaline urine. 

This division agrees with what is called primary and sec- 
ondary calculus-formation : primary being the first and sec- 
ondary the second group, to which latter is added the incrus- 
tation of a calculus from the kidney in the bladder. Prim- 
ary calculus-formation takes place only in the kidney ; sec- 
ondary, nearly always in the bladder. 
16 



122 EXAMINATION OF THE URINE. 

A separate class is formed by the so-called metamorphous 
calculi. They consist of earthy phosphates, and form a 
homogeneous, porous mass. They are always the result of 
a purulent process, continuing for years, in which the sedi- 
ment of acid urine has been dissolved by the alkaline pus 
and substituted by the earthy phosphates. 

Primary formation is begun principally by uric acid, as 
the greater number of calculi of the bladder possess a nucleus 
of uric acid. 

In 545 calculi from the bladder, Ultzmann has found the 
nucleus to consist as follows : 

Uric Acid, 441 or 80.9% 

Oxalate of Calcium, 31 or 5.6^ 

Earthy Phosphates, 47 or 8.6% 

Cystine, 8 or 1.4^ 

Foreign Bodies, 18 or 3.3% 

Analysis. 

Every calculus must be divided into two equal parts with 
a saw. The dust from the sawing must be mixed, collected, 
and examined by the key which follows. In this way all the 
principal constituents are discovered, but not their arrange- 
ments. 

In order to determine this, one-half is polished upon a 
glass plate until the various layers can be easily distinguished. 
From each layer sufficient quantity is scraped off with a pen- 
knife and this is examined separately. An illustration will 
make this clearer. 

It has been determined that the ^ of a calculus is 



CONCRETIONS. 1 23 

made up of 2 /z inorganic (non-combustible) and y$ organic 
substances. Furthermore the following substances have 
been detected : uric acid, oxalic acid, phosphoric acid, cal- 
cium, magnesium and ammonium. 

We now polish and find three layers. The nucleus, by 
the proper test, is found to consist of uric acid, the dark- 
brown middle layer of oxalate of calcium and the white 
outer layer of phosphate and carbonate of calcium and mag- 
nesium salts. 

The method for analysis is as follows : 

A few millegrammes of the powder are taken and heated 
to redness upon platinum. We must observe if there is left 
a deposit upon burning or not; whether there is produced 
a visible flame or not; whether the substance crackles 
(oxalate of calcium), and whether there is produced a 
characteristic odor. 

I. No deposit left upon burning, there may be present 
the following substances : uric acid, urate of sodium and of 
ammonium, xanthine, proteine and cystine. 

1. Proteine ', when burnt, has a yellow, luminous flame 
and causes an odor like burnt feathers or hair. 

2. Cystine burns with a faint bluish white flame, and 
produces a penerating odor of burning fat and sulphur. The 
powder is soluble in diluted ammonia and upon evaporation 
shows the characteristic crystal. 

3. Xanthine, with the murexide test, produces a pom- 
. granate-yellow color and burns without a visible flame. 

4. Uric acid, urate of sodium and urate of ammonium give 
the characteristic murexide reaction. 

(a) Urate of sodium can be distinguished from urate of 
ammonium and uric acid by the fact that at the spot upon 



124 EXAMINATION OF THE URINE. 

the platinum where the urate was burnt there remains a slight 
haziness, a piece of red litmus paper moistened and put 
upon this spot will immediately turn blue where it touches the 
haziness, due, probably, to the presence of carbonate or hy- 
drate of sodium, formed by decomposition of urate of sodium. 

(b) Urate of Am?nonium can be distinguished by the de- 
tection of ammonium. Some of the powder is moistened 
with caustic potassa ; over the mixture is suspended a piece 
of red litmus, which will be turned blue by the escaping 
ammonium. 

(c) Free Uric Acid gives negative results with both of 
these tests. 

II. If the powder is incompletely burnt, or not at all, it 
consists principally of salts of calcium and magnesium. We 
may then have the following that form calculi : oxalate of 
calcium, carbonate of calcium, phosphate of calcium and 
the triple phosphates. 

i. Oxalate of Calcium does not produce effervescence 
when hydrochloric acid is added. When heated we notice 
a peculiarity in glowing and a crackling sound. The oxalate 
has been converted into a carbonate and addition of hydro- 
chloric acid will now cause decided effervescence. 

2. Carbonate of Calcium will effervesce, without being 
heated, upon the addition of hydrochloric acid. 

3. Phosphate of Calcium and the Triple Phosphate neither 
effervesce before nor after heating. The powder, after heat- 
ing, dissolves entirely in hydrochloric acid. If to this solu- 
tion caustic ammonia is added until alkalinity has taken 
place there is found a flaky precipitate of amorphous basic 
phosphate of calcium and crystalline triple phosphate. The 
latter, under the microscope, consisting of crystals in the 
form of stars or crosses. 



REAGENTS AND APPARATUS. 1 25 



CHAPTER IV. 

Reagents and Apparatus for the Approximate exam- 
ination OF THE CONSTITUENTS OF URINE. 

It is best to have wide-necked bottles, with ground stop- 
pers, holding 250 c. c. of fluid. We give the reagents in the 

form of prescriptions : 

{a) Acids. 

1. Acid, hydrochloric. C. P., 200.00. 

2. Acid, sulphuric. C. P., 200.00. 

3. Acid, nitric. C. P., 200.00. 

4. Acid, acetic. C. P., 200.00. 

(b) Bases and Salts. 

5. Potass, fus. pur., 100.00. 
Aquae destillat., 200.00. 

6. Ammon. pur. liquid. 100.00. 

7. Barii chlorid. cryst., 30.00. 
Aquae destillat., 200.00. 
Acid, hydrochloric. 10.00. 

8. Plumbi acetat. cryst., 30.00. 
Aquae dest., 200.00. 

9. Cupri sulphat., 30.00. 
Aquae destillat., 200.00. 

10. Magnesiae sulphat. 

Ammonii chlorid. pur. aa, 30,00, 
Aquae destill., 200.00. 
Ammon. pur. liquid, 50.00. 

11. Argenti nitrat., 5.00. 
Aquae destill., 40.00. 

12. Red and blue litmus paper, cut in strips. 



126 EXAMINATION OF THE URINE. 

Besides the preceding, which are absolutely necessary, the follow- 
ing can be kept for special cases : distilled water, choride of iron, 
chloride of zinc, basic acetate of lead, nitrate of mercury, subnitrate 
of bismuth, fuming nitric acid, nitrite of potassium, starch, chloro- 
form, ether, alcohol, iodine dissolved in iodide of potassium, glacial 
acetic acid, chloride of sodium, etc. 

APPARATUS. 

i. Six test-tubes and stand. 

2. Ten wine-glasses (such as are used for sherry wine). 

3. Cylinder glasses, containing 100, 200 and 300 c. c. 

4. A graduated cylinder. 

5. A flask holding 100 c. c. with cork perforated by a glass tube. 

6. A washing bottle. 

7. An urinometer (areometer). 

8. A spirit lamp. 

9. Two small porcelain dishes. 

10. A stand of brass, with two rings. 

1 1 . Filtering paper. 

12. Four funnels. 

13. Glass rods. 

14. A microscope. 

15. A glass vessel, holding 3,000 — 4,000 c. c. 

Watch glasses, beakers, pipettes, and for quantitative purposes ap- 
paratus for volumetric analysis are necessary. 



QUANTITATIVE ANALYSIS. 1 27 



CHAPTER V. 
Quantitative Detection of Urinary Constituents. 

One condition is necessary for all quantative estimations ; 
the exact collection of all the urine passed within a given 
time. The urine is usually collected during 24 hours, and 
in order to prevent its mixture with feces, it is to be passed 
before defacation. 

We can not multiply the quantity of one hour, in order to estimate 
that of any number of hours, as the quantity of urine varies with 
■different parts of the day. 

Urine is collected in graduated cylinders. If we wish to 
find the average of excretion of any patient, it is necessary 
to collect the urine for several successive 24 hours ; then av- 
erage. 

I. Estimation of Acidity. 

In order to estimate the degree of acidity a solution of 
hydrate of sodium is added until neutral reaction sets in ; 
then compare how much of any acid (best oxalic acid) is 
required to neutralize the quantity of alkali used. 

(a) Test Solution. 

There is necessary a T n ^ solution of sodic hydrate, which contains 
0.0031 grammes NaO in 1 c. c, neutralizing 6.3 inillegrammes of 
crystalized oxalic acid. 

(£) The Test. 
Measure off 100 c. c. of urine in a beaker, then add, with 



128 EXAMINATION OF THE URINE. 

a burette, the above solution until the reation to litmus is 
negative. The number of c. c. used is multiplied by 0.0063. 
The product shows the acidity of 100 c. c. of urine reduced to 

oxalic acid. 

II. Total Solids. 

10 c. c. are evaporated to dryness in a porcelain dish, that has been 
weighed, over the water bath, this kept at ioo°C. in the air-bath for 
an hour, then allowed to cool under a dessicator, and weighed. Again 
dried and dessicated and weighed, and this operation repeated until 
no diminution in weight is observed. The difference between this 
weight and that of the dish represents the weight of the solids in 10 
c. c. of urine. Unfortunately, the result is not accurate on account 
of the reaction of the acid sodic phosphate upon urea, producing, at 
ioo° c, carbonic acid gas and ammonia, which are lost. 

Usually the approximate means are sufficiently exact for the prac- 
ticing physician. If not, the method of Neubauer ought to be used. 
( See Neubauer and Vogel, Analysis of Urine.) 

III. Urea. 
1. — The Method of Liebig. 
(a) Reagents. 

1 . Barium Solution. 1 vol. of saturated (cold) solution of barium 
nitrate is mixed with 2 vol. cold, saturated solution of barium hy- 
drate. 

2. Titrate for Urea, i, e. y solution of pure mercuric nitrate, of the 
concentration that 71.48 gr. of pure mercury, or 77.2 gr. of mercuric 
nitrate; dried, at ioo°C, are contained in 1 litre. (For preparation 
see Neubauer and Vogel) . 

Solution of Sodic Carbonate. For Raudenberg's modification, acid 
sodic carbonate must be used. This is stirred up in water, after hav- 
ing been rubbed up finely and washed by small quantities of water 
until turmeric is no longer turned brown. 

(b) The Test. 
With a pipette 40 c. c. of urine are taken, and 20 c. c. of 



ESTIMATION OF UREA. 1 29 

the barium solution added. A precipitate of phospates and 
sulphates will result. Allow to stand, and then filter into a 
dry vessel through dry paper. The filtrate is composed of 
one-third barium-solution and two-thirds urine, from 
which the sulphates and phosphates have been withdrawn. 
Of this mixture 15 c. c. are taken and poured into a dry 
vessel (only two-thirds or 10 c. c. are urine). Now allow 
the solution of mercuric nitrate to flow into the urine from 
a burette. Having used as many c. c. of the solution as are 
indicated by the last two figures of the specific gravity of 
the urine examined (thus 13 c. c. if sp. gr. is 1.015), it is 
necessary to see whether or not the limit has been reached. 
Take a drop from the mixture and put it into a porcelain 
dish, add to this a drop of sodic carbonate. If a rusty zone 
is produced, where the fluids meet, continue to add the test 
fluid ; if, however, this is pale, cease, for the work is com- 
pleted. 

The chemical" process is as follows : Upon the addition of mer- 
curic nitrate Hg(N0 3 ) 2 , it first seeks the chlorine, of the common 
salt in urine, forming HgCl 2 (corrosive sublimate). 

f N0 3 NaCl 

Kg] + = HgCl 2 + 2 NaN0 3 

(NO3 NaCl 

The NaN0 3 remains dissolved, but the HgCl 2 is precipitated, the 
solution being alkaline. After all NaCl has been converted into 
HgCl 2 , the mercuric nitrate forms a combination with the urea, by 
which N0 3 is liberated, which, upon the addition of sodic carbonate, 
takes the place of the carbonic acid ; this escaping in fine bubbles. 
NaNOgdoes not change the color of the precipitate in the porcelain 
dish. But if the limit has been reached, where all the mercuric ni- 
trate is bound to the urea, and a drop of the mixture with urine is 
added to sodic carbonate, mercuric oxide is precipitated, at the same 
time NaN0 3 being formed, and C0 2 escaping : 

x 7 



I30 EXAMINATION OF THE URINE. 

Hg(N0 3 ) 2 +Na 2 C0 3 =HgO+C0 2 +2NaN0 3 . 
HgO is precipitated as a brownish powder, which, as we now com- 
prehend, forms the limit test for the reaction. 

Having completed titration, the burette is allowed to 
stand/^r a few minutes, and we then read off how many c. c. 
have been used. 

The fluid is so arranged that 1 c. c. satisfies 10 millegrammes of 
urea, exactly. If we had used 20 c. c. there would be present 200 
mgr. of urea in the mixture (15 c. c), which was made up of 10 c. c. 
urine and 5 c. c. barium fluid. From this can be computed, without 
difficulty, how much urea is passed in 24 hours. 

1. As the test fluid is fixed for a 2^ solution of urea, we can only 
obtain accurate results when for 15 c. c. of a 2^ solution of urea, 
there is used exactly 30 c. c. of the mercury solution, of which 1 c. c. 
represents 10 mgr. of urea exactly. 

Every c. c. of the solution requires for the satisfaction of 10 mgr. 
of urea, 72 mgr. HgO. In order however, to produce the terminal 
reaction, there must be an excess of HgO. According to Liebig, this 
amounts to 5.2 mgr. for 1 c. c. of the solution, for 30 c. c. 30X5.2 
=156 mgr. If, now, to 15 c. c. of a 2^ solution of urea, 30 c. c. of 
the solution are added, the mixture amounts to 45 c. c, in which 
there are 156 mgr. of HgO in excess, /. e., 3.56 mgr. for each c. c. 
In order to effect a positive terminal reaction, then, it is necessary to 
have in each c. c. of mixture 3.46 mgr. of HgO in excess. 

If the 15 c. c. of urea solution have 3.5^ urea, 52.5 c. c. of the 
mercury solution would be required. The quantity of the mixture 
then would be 15 c. ^-[-52.5 c. €.==67.5 c » c *5 * n the 52.5 c. c. of so- 
lution is present 52.5 X5« 2===2 73 m g r » °f HgO in excess, in every c. c. 
of the mixture ; therefore, 4.04 mgr. But the termination of the re- 
action takes place with 3.46 mgr. we therefore have 0.58 mgr. too 
much. In this way the terminal reaction sets in too early. 

If the solution only contains 1 % of urea, the error would be in the 
other direction. 

In order to eliminate both errors, we proceed as follows : 



ESTIMATION OF UREA. 



131 



(a) If more than 30 c. c. of the test solution are required, add 
half as much water as the number of c. c. of test solution is more 
than 30 before testing with the sodium. Thus, as 52.5 c. c. have 
been used, we add ■£ |— 5 - = 11 c. c. of water to the mixture before 
testing with soda. 

(b) If less than 30 c. c.were sufficient, then we deduct for every 5 
c. c. less than 30 c. c, 0.1 c c. from the whole quantity used. Thus, if 
we use 20 c. c. (10 c. c. less), we compute with 20 — 0.2=19.8 c. c. 

2. If the urine contains 1 — 1.5^, NaCl, the formation of corro- 
sive sublimate will necessitate an increased amount of the test solu- 
tion, which, without being corrected, would give too great an amount 
of urea (15 to 25 mgr.) In order to correct this error, subtract 2 c. 
c. from" the figures read off from the burette. 

If we wish to get absolutely correct results, we must either first 
titrate the NaCl with a nitrate of silver solution, or use Raudenberg's 
method. According to this, two tests are made, for each of which 
15 c. c. of mixture are prepared. The one is acidulated with nitric 
acid, and the mercuric nitrate solution is added until the cloudiness 
remains permanent. With the second test we proceed according to 
Liebig, with the addition of keeping the mixture neutral by means of 
freshly precipitated calcic carbonate. For the terminal reaction, the 
solution 3 (acid sodic carbonate) is employed. We now subtract the 
c. c. used in the first test from the number used in the second, and 
from this we calculate the quantity of urea. 

3. If albumen is present, 20 c. c. are placed into a vessel that can 
be closed, a few drops of acetic acid added, and then boil until the 
albumen separates in coarse flakes ; now close the vessel and allow to 
cool. Finally, filter, and proceed as before. 

II. Method of Bunsen (Bunge). 

Only to be used when neither sugar nor albumen are present. 50 
c. c. of urine are precipitated with an ammoniacal solution of chlo- 
ride of barium, filtered and 15 c. c. of this put into a tube with thick 
walls. Upon the bottom of the tube are 3 grammes of crystallized 
chloride of barium. Seal the tube and heat to 200 C. for six hours in 
an oil bath. After cooling, break off the point of the tube, pour the 



132 EXAMINATION OF THE URINE. 

contents upon a filter, wash out the barium carbonate that has col- 
lected, and dissolve it with sufficient quantities of hydro-chloric acid. 
Care must be taken to wash off and dissolve any barium carbonate 
that may be found adhering to the walls of the tube. All of the 
solution is filtered and precipitated with sulphuric acid. The precip- 
itate of barium sulphate is collected, washed, heated and weighed. 
233 grammes of barium sulphate, representing 60 grammes of urea, 
we can easily compute how much urea is present. 

III. Method of Knop-Hufner. 

(a) Solutions. 

1. Hypobromite of sodium : 100 grammes of sodium hydrate are 
dissolved in 250 c. c. of water, and mixed with 25 c. c. of bromine. 
Must always be prepared fresh. 

2. A saturate solution of common salt. 

(b) Test 

Dilute 10 c. c. of urine with 40 c. c. of water, fill the lower cup of 
Hiifner's apparatus, and also the cock, with diluted urine, fill the 
upper part with the hypobromite solution, and the vessel above 
with the salt solution, and into it put the eudiometer. After five 
minutes the development of gas ceases. After one hour the eudiom- 
eter is taken off, and the quantity of urea is calculated according to 
the method of Dumas, 1 gramme of urea producing 370 c. c. of nitro- 
gen (at 0°C and 760 m.). 

IV. Estimation of Uric Acid. 

To 300 c. c. of urine are added 10 c. c. of hydrochloric 
acid, well stirred, and allowed to stand in a cool place for 
48 hours. If the urine contains albumen, this must be re- 
moved. If it contains sugar, it must be treated with mer- 
curic acetate ; the precipitate being washed upon a filter, it 
is mixed with a little water, then hydrogen sulphide allowed 
to act upon it, and again filtered. The mercuric sulphide is 



ESTIMATION OF URIC ACID. I33 

washed with warm water, this water then is treated like the 
urine. 

The crystals of uric acid are collected upon a filtering 
paper that has been washed with water and acetic acid, 
dried between two watch-glasses at ioo° c. and then 
weighed. As the crystals of uric acid are very heavy, 
they can be collected by decanting the fluid ; those crystals 
that adhere to the walls of the vessel can be removed by a 
feather, and will then come to the bottom. 

Only when the crystals are very small does it become 
absolutely necessary to filter. 

Uric acid is washed with distilled water until the filtrate no 
longer produces any reaction with nitrate of silver. It is ad- 
vantageous not to use more than 30 c. c, otherwise some 
of the uric acid is dissolved. If more than 30 c. c. are em- 
ployed, then 0.045 m & r « must be added to the whole amount 
of uric acid for every c. c. of urine. 

Now the uric acid is dried at ioo° c. between watch 
glasses in the air bath, dried in the dessicator, and weighed. 

The difference between the two weighings represents the 
weight of uric acid contained in 300 c. c. of urine. 

Schwanert recommends to add for every 100 c. c. of urine employed 
0.004S grammes, claiming that the result is more correct. 

V. Estimation of Creatinine. 
(a) . Reagents. 

1. Zinc- Chloride Solution. Pure oxide of zinc is dissolved in pure 
hydrochloric acid ; this solution is evaporated in the water bath to the 
consistency of syrup (until no free acid can be detected), dissolved in 
strong alcohol until specific gravity of 1,200 is reached. 

2. Milk of Lime, To be shaken before using. 

3. Dilute Solution of Calcium Chloride. 



134 EXAMINATION OF THE URINE. 

(b). Test. 

200 c. c. are rendered alkaline with the milk of lime and the cal- 
cium solution added as long as a precipitate is formed. After 2 hours, 
filter, wash and concentrate everything having come through the 
paper, in the water bath, to the consistency of a thick syrup. Add, 
while warm, 50 c. c. of alcohol (95^), poui into a beaker and allow to 
stand for eight hours. Again filter and wash, and evaporate to 60 c. c. 

After cooling add y z c. c. of the chloride of zinc solution, stir 
with a glass rod and allow to stand for 48 hours. A compound with 
chloride of zinc is formed which is treated like the crystals of uric 
acid. In 100 parts of this compound are found 62.44 P arts °f Creati- 
nine. 

VI. Estimation of Total Nitrogen. 

The principal amount of nitrogen in urine is contained in urea, and 
as Liebig's method includes other nitrogenous substances, this usually 
suffices. 

The direct method is usually performed by burning with soda-lime. 
(a.) Reagents. 

1 . Fresh Soda Lime. 

2. Normal sulphuric acid, containing 40 grammes of sulphuric acid 
anhydride in 1 litre of water, every c. c. corresponding to 0.014 
grammes of nitrogen. 

3. Solution of Caustic Soda f equivalent to the sulphuric acid, i. e., 
10 c. c. of the one must neutralize 10 c. c. of the other. 

4. Litmus Tincture. 

(l>). Test. 

Pour 20 c. c. of sulphuric acid into a beaker and then suck the 
greater part into the nitrogen apparatus of Will-Varrentrapp. Into a 
flask holding 100 c. c; soda lime, to the depth of 2 c. c. and 5 c. c. of 
urine are put, the flask closed with a cork having two openings, and 
the whole placed into a sand bath. Through the one opening of the 
cork the connecting tube with the nitrogen apparatus passes, through 
the other passes a fine tube drawn out at one end and closed. Heat 
the sand bath as long as bubbles of gas pass through the apparatus. 
When this has ceased, break off the end of the fine tube and draw out 



ESTIMATION OF ALBUMEN, I35 

all the ammonia from the flask. Now the contents of the apparatus 
are poured into the beaker before mentioned; put a few drops of the 
litmus tincture into the fluid and add the caustic sodium solution until 
the red color is changed to blue. 

If, by decomposition, no ammonia had been formed, we would have 
to have added 20 c c. of soda to neutralize the 20 c. c. of normal 
sulphuric acid. If 14 c. c. only are necessary, it proves that 6 c. c. of 
sulphuric acid have been satisfied by the ammonia formed, 1 c. c. 
corresponding exactly to 0.014 grammes of nitrogen, the quantity of 
N. present will equal 6X0.014=0.084 grammes N in 5 c. c. of urine. 
From which the quantity passed in 24 hours can easily be found. 

VII. Estimation of Albumen. 

Filter the urine and take ioo c. c. (where little albumen 
is present), 50 c. c. (where more is present, dilute with 50 c. 
c. of water), or 20 c. c. (where great quantities are present 
dilute with 80 c. c. of water), which is to be heated for half 
an hour in the water bath. If the albumen does not come 
down in coarse flakes add 1-2 drops of acetic acid and con- 
tinue to heat. Allow the fluid to pass through a weighed 
filter and wash with distilled water until the wash water 
ceases to show the Na CI reaction with Ag No 3 . The filter 
is then dried between watch-glasses at ioo c. and weighed. 

VIII. Estimation of Sugar. 

fehling's method. 

(a). Solution. 

Fehling's Solution. In 1,000 c. c. are contained 30,639 grammes 
cupric sulphate, 173 grammes pure, crystallized tartrate of sodium and 
potassium, and 500 grammes of solution of caustic soda (sp. gr. 1.12). 
10 c c. of this solution are reduced by 0.05 gr. of sugar. 

(b). Test. 
The estimation of sugar depends upon the property of 



136 EXAMINATION OF THE URINE. 

grape sugar of reducing cupric sulphate in the presence of 
an alkali. For this purpose urine is taken and filtered and, 
if the quantity of sugar present is not too small, dilute with 
water. Usually 10 c. c. of urine are diluted with 190 c. c. 
of water. With this mixture a burette is filled. A flask or 
porcelain dish is placed upon a wire net, and into it 10c. c 
of Fehling's solution diluted with 40 c. c. of water. Now 
heat, and, as soon as boiling takes place, add the urine 
drop by drop. Gradually the fluid becomes yellow, then 
red; finally, all the blue disappears and the red cuprous 
oxide precipitates very quickly. If allowed to stand for a 
little while the solution will be found entirely colorless, or, 
if too much urine has been added, slightly yellow. The 
entire discoloration, then, is the terminal reaction. 

As this can not always be readily determined with the 
naked eye, it is advisable to filter a few drops into a test 
tube, testing one part of the fluid, having acidulated it with 
acetic acid, with ferro-cyanide of potassium for copper, and 
the other with Fehling's solution for sugar. If neither are 
present then the reaction has been completed. 

In the estimation for sugar it is of essential importance to compute 
the amount of urine employed. 

Supposing that we have used 25 c. c. of the urine mixture to reduce 
to c. c. of Fehling's solution. The mixture was prepared so that 200 
c. c. contained only 10 c. c. of urine. In order to find out how much 
urine there is in 25 c. c. of the mixture we institute the proportion : 

200 : 10: : 25 : x. x=i.25 c. c. 

1.25 c. c. of urine, therefore, was able to reduce 10 c. c. of Fehling's 
solution completely. But the solution is so arranged that 10 c. c. will 
reduce 0.05 gr. of sugar, 10 c. c. of the solution being reduced by 
1.25 c. c. of urine, the latter must contain 0.05 gr. of sugar. From 
these data we can easily compute how much sugar is passed in 24 
hours. 



ESTIMATION OF SUGAR. I37 

If albumen is present it must be removed by the method already de- 
scribed. 

Note. — When Fehling's solution has been kept for some time it be- 
comes self-reducing. It is, therefore, necessary before using the 
solution to boil it in a test tube, and if reduction does not take place 
it can be used for the test. By means of placing the solution in small 
bottles (containing about 15 c. c. ) with glass stoppers, hermetically 
sealing and keeping them in a cool place, the solution will retain its 
delicate properties for years. (Tr.) 

2. Knapp's Method. 
(a) Solution. 

10 grammes of pure mercuric cyanide are dissolved in a little water. 
To this is added 100 c. c. of a solution of caustic soda (sp. gr. 1.145) 
and the whole diluted to 1,000 c. c; 40 c. c. of this solution reduce 
100 millegrammes of sugar. 

ip) Test. 

Heat 40 c. c. of the solution in a beaker and add diluted urine, as 
in Fehling's test, until the originally-clouded mixture becomes clear 
and yellowish. From time to time a drop is taken out and tested 
with ammonium sulphide. As soon as the spot no longer shows a 
brown circumference the test is complete. Fehling's method and this 
one do not give results that correspond exactly. 

The method, by fermentation, is much more laborious and not as 
exact as Fehling's. Very accurate results are obtained with the 
saccharimeter of Soleil-Ventzke or the polaris trobometer of Wild. 
(See Neubauer and Vogel.) 

IX. Estimation of Chlorine. 

I. AFTER MOHR. 

(a) Reagents. 

1 . Saturated solution of potassic chromate. 

2. Titrated solution of silver nitrate^ containing 29,075 gr. of 
AgN0 3 (18,469 gr. Ag) in a litre, so that ic.c. represents 10 mgr. 
of Na CI (=6,065 mgr. CI). 

3. Calcic Carbonate. 

18 



138 EXAMINATION OF THE URINE. 

(b). Test. 

10 c. c. of urine are measured into a platinum crucible ; 
add 2 grammes of pure nitre, evaporate to dryness over a 
water bath, heat over a Bunsen's burner until the melted 
mass no longer contains any carbon. Dissolve in a little 
water and carefully rinse the crucible. Solution and rinsings 
are carefully collected in a beaker, nitric acid, free from 
chlorine, is then added until a weak acid solution is produced, 
which is then neutralized, carefully, with freshly-precipitated 
calcium carbonate. Without regard to the precipitate, three 
drops of chromate solution are added and then the silver 
solution is allowed to flow into the mixture. As soon as the 
yellowish fluid becomes reddish, it is a sign that all the com- 
mon salt has been converted into chloride and that the for- 
mation of silver chromate has begun. At this moment the 
work is completed. 

If for 10 c. c. of urine we had used 9.6 c. c. of the titrated fluid 
we would have 96 mgr. of NaCl present as 1 c. c. of the fluid indicates 
10 mgr. NaCl. 

From this we can readily determine how much NaCl present in 24 
hours. 

If the patient has been receiving iodine or bromine preparations, it 
becomes necessary to remove these from the urine. In order to carry 
this out, add to the solution, as it comes from the crucible, sulphuric 
acid, then a few drops of potassium nitrite, then shake with bisulphide 
of carbon, as long as this takes up I or Br, then neutralize with natri- 
um carbonate, and proceed as above. 

X. Estimation of Phosphoric Acid. 

(a) Reagents, 

1. Solution of Natrium Acetate. 100 grammes of the salt dissolved 
in 900 c. c. distilled water and 100 c. c. of concentrated acetic acid 
added. 



ESTIMATION OF PHOSPHORIC ACID. 139 

2. Solution of uranic nitrate, 1,000 c. c. containing 20.3 gr. pure 
uranic oxide. 1 c. c. represents 5 mgr. of phosphoric acid. 

3. A Solution of Potassium Ferro-cyanide. 

(b) Test. 

50 c. c. of urine are measured into a beaker, mixed with 
5 c. c. of the solution of sodium acetate and heated in a 
water bath. Then add the uranium solution as long as a 
precipitate continues to form. If this point cannot be de- 
termined accurately, place a few drops upon a porcelain dish, 
and, if upon addition of the potassium ferro-cyanide, a 
brownish-red boundary line is produced, cease adding the 
uranium solution and again heat in a water bath. See if a 
precipitate will now form. Usually this is not the case; then 
a few drops of the uranium solution are added so that the 
ferro-cyanide test succeeds with the boiling mixture. The 
border reaction then sets in, when all the phosphoric acid has 
been precipitated by the uranium, in that the next drop, 
finding no acid, is precipitated brown by the ferro-cyanide of 
potassium. 

If we have used 13 c. c. of the solution, for instance, we could es- 
tablish the following proportion (1 c. c.=5 mgr. of phosphoric acid): 

1 : 5 :: 13 : x ; x=65 mgr. 

From which, the quantity of urine in 24 hrs. being known, the amount 
in 24 hours can be easily computed. 

If we wish to determine the phosphoric acid that is bound to the 
earths ; 200 c. c. of urine are precipitated with ammonia. The precip- 
itate is collected ; after 12 hours, upon a filter, washed with aqua am- 
monise (1 part in three of water), the filter perforated, and the precip- 
itate washed into a beaker. The precipitate is then dissolved with a 
small quantity of acetic acid, 5 c. c. of the solution of sodium acetate 
added, diluted to 50 c. c. and examined as above. 



I40 EXAMINATION OF THE URINE. 

The difference between the total phosphoric acid and the phos- 
phoric acid in combination with the earths, will give the phosphoric 
acid united to the alkalies. 

XI. Estimation of Sulphuric Acid. 

ioo c. c. of urine heated and precipitated with barium chloride; the 
barium sulphate that is formed is collected upon a filter, of known 
weight, washed, burnt in a crucible whose weight is also known, mois- 
tened with a few drops of sulphuric acid, and again heated. Then the 
whole is weighed, the difference between total weight and weight of 
crucible-)- filter, representing the weight of barium sulphate. As 
34.33 parts, by weight, in 100 parts of barium sulphate, represent 
sulphuric acid, the latter can be easily determined. 

For the exact quantitative tests, see Neubauer & Vogel, Hoppe- 
Seyler, etc. 



APPROXIMATE ANALYSIS. 141 



CHAPTER VI. 

Key to the Approximate Analysis of Urine. 

After having allowed the urine to stand for several hours, 
we first determine its physical properties : 

1. The quantity in 24 hours. 

2. Color and transparency. 

3. Odor. 

4. Reaction to litmus. 

5. Specific gravity. 

6. Quantity of Sediment. 

If sediment has formed, the urine is poured off and exam- 
ined. If very cloudy it must be filtered, and if the filtrate 
still is cloudy, slightly heating will clear it. The sediment is 
kept for further examination. 

Chemical Examination. 
(A) nitric acid test. 
About 15 c. c. of clear urine are taken, and 5 c. c. of 
pure nitric acid are allowed to flow under it. We here find: 

1. Albumen. 

2. The urates. 

3. Biliary coloring matters. 

4. Indican. 

When much iodine is present, the ring of coloring matter 
between the nitric acid and urine, is colored yellowish 
brown, and the odor of iodine is distinctly present. 



142 EXAMINATION OF THE URINE. 

Very minute quantities of these substances are only sepa- 
rated after some time ; it is, therefore, of importance to put 
the vessel aside, and examine the result after a little time 
has elapsed. The next is the 

(B) Test by Boiling. 

Fill a test-tube one-third full with clear urine, and boil 
over a lamp. If turbidity is produced, there is present 
either albumen or the earthy phosphates. Add i — 2 drops 
of acetic acid ; the phosphates are dissolved — not so the al- 
bumen. Now add liquor potassae, one-half the quantity 
that we added of urine ; albumen dissolves, but, at the same 
time, the earthy phosphates are brought down in the form 
of fine flakes. Now boil again. If the mixture becomes 
brown, sugar is present ; if this does not occur, put the test- 
tube on a stand, and, after having allowed the precipitate 
to settle, determine its quantity and color. 

In normal urine this always is white ; if colored, then 
there may be present various coloring matters. If it appears 
blood-red or dichroic, then blood-coloring matter is present 
In confirmation, albumen must be present and haemine crys- 
tals must be detected by the proper methods. Nearly 
always, blood corpuscles will be detected. 

If the precipitate is pink, and the urine does not contain 
albumen, then vegetable coloring matter is present (especially 
after taking senna or rhubarb). In order to verify this, the 
urine must, upon addition of ammonia, become reddish, 
which will again disappear when acids are added. 

If the precipitate is grayish, then uroerythrine, the coloring 
matter of fever urine, is present. This is verified by the 
presence of a brick-dust sediment, or the production of 



APPROXIMATE ANALYSIS. 143 

a reddish or flesh colored precipitate upon the addition of 
a solution of plumbic acetate. 

A brown color of the precipitate indicates biliary coloring 
matter. If the same is not decomposed, Heller's test will 
give a beautiful play of colors. This failing, it is decomposed; 
then the sulphuric acid test must be increased, the specific 
gravity being low, as well as a mixture of urine with a solu- 
tion of caustic potash, must appear dark. 

(C) Test for the Normal Coloring Matter of Urine. 

1. Test with concentrated sulphuric acid (Heller's Uro- 
phaei'ne). 

2. Test for indican with concentrated hydrochloric acid 
and calcium chloride solution. 

(D) Test for the Normal Inorganic Salts. 

1. For the chlorides. The vessel in which the test (A) 
has been performed can be used; the two layers are stirred 
with a glass rod, and then i or 2 drops of the nitrate of 
silver solution are added. 

2. For the alkali phosphates with the magnesia fluid and 

3. For the sulphates with chloride of barium. 

{E) Tests for Abnormal Substances. 

If necessary, test for ammonium carbonate, sodium carbonate, 
sulphide of hydrogen, leucine and tyrosine. These can be deter, 
mined by the preceding tests. 

(F) Examination of the Sediment. 

First determine color and consistency of the sediment 
(whether crystalline, a powder, flaky, etc.); then its compo- 
sition. This can be done either chemically or, better, mi- 



144 



EXAMINATION OF THE URINE. 



crochemically and microscopically. Finally, we determine the 
organized admixtures (epithelium, casts, spermatozoa, etc.) 

Having examined an urine according to this method, it is 
of importance, especially for the beginner, that all the results 
are noted in a brief and schematic way so that an oversight 
can be had and the result easily deduced. 

The following method can be used to great advantage : 



Physical Properties. 



Normal Substances. 
H 2 S0 4 Test. CI. 

Ind. " Eph. 

+ 

U. Aph. 



U. 



Sph. 



Abnormal Substances in Solution. 



Sediment. 



Result. 



APPROXIMATE ANALYSIS. 1 45 

Divide a sheet of paper into four parts; the upper for the 
enumeration of the physical properties, the second for the 
quantity of normal constituents present. The abbreviations 
employed are as follows : 

H 2 S0 4 test = Sulphuric acid test for coloring matter. 
Ind. = Indican. 



+ 
u. 


= Urea. 


u. 


= Uric acid. 


CI. 


r= Chlorides. 


Eph. 


= Earthy phosphates. 


Aph. 


= Alkaline phosphates. 


Sph. 


— Sulphates. 



In order to express whether a substance is present in nor- 
mal, greater or smaller quantity, the following are employed: 
For an increase the sign -|-; for diminution the sign — : for 
normal the letter "n K . A great increase or diminution are 
represented by "gr.+" and "gr. — ;" also, a moderate in- 
crease or diminution by "m+" and "m — " 

The third division is for the abnormal substance found in 
solution. 



19 



146 



EXAMINATION OF THE URINE. 



The last for the description of the sediment and the result, 
the diagnosis. A sheet of paper filled out looks like the 
following : 



Physical Properties. 

Quantity = 4,000 c. c. 

Pale yellow, somewhat cloudy, acid. 

Sp. gr. a- 1,040; Slight sediment. 



H 2 S0 4 test 
Ind. - - • 

*!■■ 

u. 



■ m.+ 



CI. 
Eph. 

Aph. 
Sph. 



m- 
gr.- 



}°- 



Abnormal Substances in Solution. 



Sugar in large quantities. 



Sediment. 

Consists of mucus in normal quantity. 
Microscopically a few yeast fungi are detected. 

Result : — Diabetes Mellitus. 



Using a blank like the above will facilitate, not only the 
analysis but also the diagnosis. Coming back to the above 
we deduce as follows : 

1. From the quantity in 24 hours; Polyuria, 



GENERAL DIAGNOSIS. 1 47 

2. From the specific gravity, and the amount of solids 
found by computation from it ; Diabetes. 

3. From the pale color and the absence of the urates ; 
the absence of fever. 

4. Finally, from the presence of sugar ; Diabetes mellitus. 



CHAPTER VII. 

General Diagnosis. 



At a time when the examination of urine consisted solely 
of a prejudiced observation of physical properties; when the 
so-called " urine signs" were forced into a system the re- 
sult of dreams, it was impossible for the examination of 
urine to be an aid to the discovery of pathological processes, 
it frequently serving to cover over ignorance and quackery. 

It is only since organic chemistry and microscopy have 
progressed; since the connection between the composition of 
urine and the changes in the economy, on the one hand, and 
the structure of the urinary apparatus on the other, have been 
thoroughly recognized, that the analysis of urine can be 
termed a scientific procedure. No one doubts, at the present 
time, but that it is of great value in the diagnosis of disease, 
in some cases it alone giving us an insight into the stage, the 
nature and intensity of the disease. . We would err if we 
would consider ourselves capable of diagnosticating all forms 
of disease from the urine, but it seems equally unjustifiable 
to neglect this branch entirely. 



I48 EXAMINATION OF THE URINE. 

Before proceeding to the diagnosis of the diseases of the 
urinary organs we will mention the important general rules. 

We take up that order which is of greatest importance to 
the practicing physician. 

1. Measure the quantity of urine passed in 24 hours and 
determine whether normal, increased or diminished. The 
normal quantity is, about, 1,500 c. a; if the quantity is very 
much above this, we have polyuria; if very much below, 
oliguria, and, if no urine whatsoever is passed, anuria. 

Polyuria may be physiological or pathological. In the for- 
mer instance it is urina potus or urina spastica, and in the 
latter, hydruria or diabetes. In order to make this differential 
diagnosis we compute the amount of solids in 24 hours, by 
Trapfs or Haeser's coefficient. If this amount is nearly 
normai (70 gr.), then we have an urina potus, i. e., an urine 
with normal solids that has been diluted. If the solids are 
diminished, then it is hydruria, as observed in many cachexias. 
If the solids are very much increased, then we have diabetes; 
— sugar being detected, in appreciable quantity, in the latter 
instance, it is diabetes mellitus, no sugar being present, diabe- 
tes insipidus, (when the nitrogenous substances are increased, 
azoturid). 

Oliguria can be readily diagnosticated and occurs princi- 
pally in febrile diseases. The urine usually is dark and 
very much concentrated. In the last stages of disease of 
the kidney, when uraemia sets in, the quantity of urine is 
always diminished. A mild form of oliguria may also be 
congenital; temporarily it is produced by the abstraction of 
water, after profuse sweats or after diarrhoea. 

Anuria, the uretha being pervious, can only occur in grave 



GENERAL DIAGNOSIS. 149 

disorders of the kidney with uraemia ; at other times it is 
found in strictures, calculi and neoplasms as so-called re- 
tention of urine. 

Having satisfied ourselves regarding the quantity, we seek 
to determine whether . 

2. The urine is indicative of a febrile state or not. 
From this we can frequently see if the process is acute or 
chronic, the former usually being accompanied by higher 
degrees of fever. 

The urine of fever is usually dark, reddish-yellow, concen- 
trated and diminished in volume. If the quantity is not di- 
minished, rather increased; occurring very rarely, the color- 
ing matter of urine will, nevertheless, be found increased. 
With the nitric acid test a distinct layer of urates can always 
be detected. 

If an acute exudative process is present, then, in the 
stage of exudation, the urine is concentrated, acid, con- 
taines many urates, that come down, when cold, in the 
form of brick-dust sediment. At the same time urea, the 
sulphates and the alkaline phosphates are increased; the 
chlorides, on the other hand, diminished. With the in- 
crease of disease the chlorides diminish and may be en- 
tirely absent. 

In the stage of absorption the concentration of the urine 
gradually dimishes, the reaction becomes neutral or alkaline 
(ammonium carbonate); the chlorides are again present in 
normal quantity and in the sediment are found urates (in the 
form of urate of ammonia) and the earthy phosphates. At 
the same time the quantity of urine may be normal or even 
diminished. 

We can readily diagnosticate the febrile state, but can not 



150 EXAMINATION OF THE URINE. 

diagnosticate the form of fever (except febrile diseases of the 
urinary apparatus). Even in diseases of the kidneys we may 
err in that we may take an accompanying disease to be the 
principal affection. We examine, for instance, the urine of 
scarlatina. We find a febrile state, in addition, however, 
a desquamative or parenchymatous nephritis. As a result of 
the uroscopic developments we can only diagnosticate an 
acute nephritis, which evidently only accompanies the scar- 
latina, the latter not being detected by the analysis. 

Differential diagnosis between the different forms of fever, 
then, is impossible; but, nevertheless, we ought to examine 
the urine, as from it we can discover increase or diminution 
in the process, or other complications. The reappearance 
of the chlorides, for example, is considered a favorable sign, 
their disappearance or the appearance of albumen an unfavor- 
able one. 

Among the febrile processes there are some that require 
mention on account of their giving to the urine certain char- 
acteristic properties. 

We find: 

In jaundice, constituents of bile always present in the urine. 

In jaundice that is mild {icterus levis), produced by absorp- 
tion of bile, we find only a febrile state, and a goodly quan- 
tity of -biliary coloring matter; the chlorides are sometimes 
diminished. 

In severer forms of jaundice produced by disease of the 
liver (icterus gravis), we find, besides great quantities of urates 
and biliary coloring matter ; albumen and, sometimes, small 
quantities of biliary acid. The chlorides are usually absent. 

In acute yellow atrophy of the liver we usually find an urine 
rich in biliary coloring matter, having a low sp. gr. and acid 



GENERAL ANALYSIS. 151 

reaction. Urea is much diminished and, in its stead, we 
find leucine and tyrosine. The chlorides disappear, besides, 
the urates and albumen are present, the latter in abundance. 
Even biliary acid may be detected in this urine. In the sed- 
iment are found great numbers of epithelial tubes and fibrine 
casts; in addition, epithelium from the kidney and blood cor- 
puscles. 

In acute pulmonary affections we find a great quantity of 
urates. In diseases of the heart or irregularities in circula- 
tion, we find stasis in the venous system and, as a result, 
albuminuria (hyperaemic kidney). In peritonitis ', we usually 
find large quantities of indican (Senator). 

The urine of meningitis is usually very much concentrated, 
corresponding to the slowness of the pulse. As the dif- 
ferential diagnosis between typhus and meningitis is very 
difficult, frequently impossible clinically, the urine has been 
looked to for assistance. Unfortunately this can not be 
relied upon. It is said that the urine of meningitis has a 
high specific gravity, a faintly acid reaction and contains an 
increased amount of urates besides a small quantity of albu- 
men. In addition, it is claimed that when the urine of this 
disease is boiled, the earthy phosphates are precipitated 
without the addition' of an alkali; the chlorides are not very 
much diminished. For typhus the urine is described as hav- 
ing a lower specific gravity, acid reaction and no spontane- 
ous precipitation of phosphates; the chlorides are always 
much diminished. The urates are present; albumen may 
also be found in considerable quantity. At the same time, 
however, the urine of typhus is said to have large quantities 
of ammonium carbonate in solution, although the reaction is 
acid. In meningitis spinalis much indican has been found. 



152 EXAMINATION OF THE URINE. 

In contradistinction to meningitis cerebralis, the sp. gr. is 
said to be diminished (Heller). 

In acute articular rheumatism, in addition to high specific 
gravity, acid reaction, increase in urea and in urates, a great 
increase in the earthy phosphates is claimed as characteristic. 
The sediment contains pink urates and calcium oxalate col- 
ored by uroerythrine. If pericarditis sets in, the chlorides 
and earthy phosphates are rapidly diminished, but the uro- 
erythrine becomes even better marked than before. 

If the urine is not colored dark yellowish red and does 
not contain urates in large quantity, then we can assume 
that the disease is not accompanied with fever. For a few 
of those diseases that are without fever, therefore principally 
chronic, characteristic properties of the urine have been 
described which are enumerated on account of completeness. 

Chlorosis furnishes a very pale urine, of low sp. gr. corres- 
ponding with the diminished waste of tissue in the body. In 
hysteria the urine is similar, but the quantity is sometimes, 
and indican is always, increased {urina spastic^ Very pale 
urine is found, also, in hydruria and diabetes. In diabetes 
mellitus the sp gr. is increased; usually there is found an 
increase in indican, and in the late stages of the disease, 
albumen is present. The other normal constituents are di- 
minished in per centage but increased absolutely (with the 
exception of uric acid). In diabetic urine handsome yeast 
fungi, as well as networks of penicillium, are frequently 
found. 

In chronic diseases of the spinal cord there occurs fre- 
quently a pale and light urine, which, in addition to much 
indican, and sometimes albumen, is said to contain sugar. (?) 
Heller states that in the sediment he has frequently observed 
sarcina. 



GENERAL ANALYSIS. 1 53 

In rickets and malacosteon the earthy phosphates are very- 
much increased, so that they form a heavy deposit. 

In diseases of the bones f when they affect any great amount 
of osseous substance, the calcium salts are frequently found 
increased in the urine, in the form of the oxalate as well as 
the earthy phosphates, both in solution and in the sediment. 

A very acid and concentrated urine is found in chronic 
rheumatic arthritis, depositing a copious sediment of urates 
and oxalate of lime. A decided increase in earthy phos- 
phates is claimed as characteristic. 

In gout the urine is similar to that of the above, only that 
uric acid is diminished in the urine and deposited in internal 
organs. Occasionally, however, a beautiful deposit of free 
uric acid is found. 

In intermittens, during the chill, the urine is increased, 
pale and transparent; whilst it is dark during the period of 
fever. 

In chronic diseases of the liver, notwithstanding the absence 
of fever, we find a dark, acid and concentrated urine. 
Biliary coloring matter that is not decomposed is rarely 
present. But we find the tests for normal coloring matter 
much increased — usually uroery thrine is present. The increase 
in these coloring matters is said to depend upon the presence 
of decomposed biliary coloring matter and increase in their 
excretion^ The earthy phosphates are commonly dimin- 
ished. In the sediment are found urates, and sometimes 
oxalate of calcium, both colored by uroerythrine. In skin 
diseases of a chronic nature, and especially m those in which 
a great area of skin becomes disabled for perspiration, we 
frequently find kidney disease as a complication, for instance, 
pemphigus, etc. 
20 



154 EXAMINATION OF THE URINE. 

In scorbutus and purpura haemorrhagica hemorrhages 
from the kidney are not uncommon. Also in melanaemia, 
where parenchymatous diseases of the kidney are found in 
addition. 

In leucaemia the urine is loaded with uric acid, lactic and 
hippunc acids also occurring. 



CHAPTER VIII. 

Diagnosis of Diseases of the Urinary Apparatus. 

If we can prove the presence of albumen in urine that 
does not contain pus, blood or any other albuminous fluid, 
then we have before us a case of true albuminuria. We are 
then dealing with a disease of the kidney. If blood and pus 
are present in large quantities, and albumen in corresponding 
quantity, then we have a case of false albuminuria, due to 
disease of the pelvis, the ureters or the bladder. If pus or 
blood are present and great quantities of albumen are de- 
tected, then we are dealing with mixed albuminuria (Vogel). 

Great practice alone capacitates for determining whether 
albumen is present in sufficiently large quantity to constitute 
mixed albuminuria. This can be acquired by means of 
mixing with normal urine pus from wounds and then testing 
for albumen. 

Microscopic and Chemical Aids for the Diagnosis of 

Various Forms of Albuminuria. 

(a) true albuminuria. 

i. Hyperaemia of the Kidney. 

In active hyperaemia, depending upon the imbibition of 



HYPERAEMIA OF THE KIDNEY. 



*55 



much fluid, no albumen is found. The quantity in 24 hours 
is very much increased; color of the urine, pale yellow, 
even watery, the sp. gr. very low. Normal constituents are 
usually increased. 

It is only when the kidneys have been over-exerted for 
some time, as in diabetes, that we find albumen present in 
small quantity. In the same way albumen is found in hy- 
peraemic conditions of the kidney Q %, usually less) that 
are caused by irritating substances excreted by the kidneys. 
For example, after the continued administration of balsam 
copaibae, turpentine, cubebs, corrosive sublimate and other 
acrid remedies. 

The chemical composition of the urine must also be con- 
sidered as cause for an irritated condition; 1. e., hyperaemia 
of the kidneys. It is well known that urine very much con- 
centrated, or very acid, can cause the most varied symptoms. 
Occasionally, mostly transient, albumen is found in such 
urine. 

In oxaluria and the presence of large quantities of uric 
acid, partly on account of mechanical, partly chemical, 
irritation, especially when the urine is very acid and the 
crystals of uric acid are lance-shaped, albumen can be de- 
tected in small quantity. In these cases it usually disappears 
upon the internal administration of alkalies, excellent sol- 
vents for urates and oxalates. This form is not infrequently 
the first beginning of calculus of the kidney. 

A transitory presence of albumen, in small quantities, is 
detected after convulsions, epileptic attacks, attacks of chills 
and fever, and in various forms of spasms of the blood ves- 
sels; frequently in acute febrile diseases (febrile albuminuria 
of Bartels), especially in the acute exanthemata, not infre- 



156 EXAMINATION OF TH2 URINE. 

quently in other inflammatory affections of the skin, anthrax, 
furunculosis, erysipelas, after burns, etc. Not uncommonly 
in hyperaemia, there is begun a parenchymatous affection if 
the cause continues to act. 

In passive hyperaemia, occurring as a result of stasis in 
the venous circulation, the albumen increases and diminishes 
with increase or diminution of pressure. 

This form of kidney is most commonly found in valvular 
lesions of the heart that have not been compensated. Regu- 
lating the circulation by proper remedies causes the albumen 
to disappear. The hyperaemic kidney is also found in 
chronic diseases of the lungs, notably in emphysema; further- 
more in tumors and exudations that prevent the flowing back 
of the venous blood ; for example, large pleuritic exudations, 
ascites, ovarian tumors and pregnancy. In puerperal con- 
vulsions we do not always find the hyperaemic kidney (Ros- 
enstein), but very frequently parenchymatous nephritis (Bar- 
tels). 

As a result of marasmus and cachexia we also find this 
form of disease. 

The urine, in simple hyperaemia of the kidney, is as fol- 
lows: sp. gr. increased, but not always; the quantity either 
diminished or normal; reaction acid. 

Albumen present in small quantity ( i Q % and below ). 

In the sediment are found either no organized elements or 
blood corpuscles and epithelia from the straight uriniferous 
tubules. Hyaline casts hardly ever occur. 

In febrile albuminuria the quantity of urates is increased, 
and that of the chlorides very much diminished. 

In the hyperaemic kidney proper (stasis,) the quantity is 
always diminished, sp. gr. high, color dark,and the reaction 
acid. 



ACUTE PARENCHYMATOUS NEPHRITIS. 157 

The urine contains a great quantity of urates that fre- 
quently cause the urine to become cloudy and form a large 
deposit. 

Albumen is present 5 % and above. 

In the sediment are found hyaline casts and kidney 
epithelium. 

This form can be differentiated from parenchymatous 
nephritis by the absence of cellular elements (blood, lymph 
corpuscles and granular epithelium of the kidney) and gran- 
ular casts in the sediment. 

From chronic interstitial nephritis and the amyloid kidney, 
by the dark color of the urine, its high sp. gr., its diminished 
quantity and richness in urates. 

Parenchymatous Nephritis. 

There are two forms of parenchymatous nephritis : acute 
and chronic. The acute form is rarely primary, but de- 
veloped from some other disease; the chronic is usually 
primary, and forms the second stage of what is called 
Bright' s disease by the authors. 

(a) acute parenchymatous nephritis. 

Again, a subdivision can be made, a mild form, so-called 
catarrh of the uriniferous tubules or desquamative nephritis, 
and the real acute parenchymatous (diffuse or croupous) ne- 
phritis, the so-called acute Bright's disease. 

(a) CATARRH OF THE URINIFEROUS TUBULES, OR DESQUAM- 
ATIVE NEPHRITIS. 

Attacks principally the straight uriniferous tubules. The 
disease lasts from 8 to 14 days, frequently less. The 
patients have tittle fever ; they complain of pain in the limbs, 



158 EXAMINATION OF THE URINE. 

weakness and pains in the back. Frequently the disease 
runs its course without compelling the patient to seek his 
bed. We rarely find oedema. 

The urine presents the following changes : 

The quantity is either normal or slightly diminished, the 
same is true of the sp. gr. The color of the urine is wine 
yellow, rarely yellow; the reaction acid. It is always cloudy 
from admixture of cellular elements and frequently deposits 
a dense sediment. 

The normal constituents are unaltered. Of abnormal 
substances albumen is found in } Q — 5 % , and traces of 
blood coloring matter. 

The sediment is principally made up of an increased mu- 
cous secretion. With the microscope we find numerous 
epithelial cells from the straight tubules, usually little altered, 
sometimes colored brownish by the blood coloring matter. 

They are frequently adherent to each other, forming the 
epithelial tubes or stick to hyaline casts forming epithelial 
casts. Besides, are found single hyaline casts, red blood 
corpuscles and lymph corpuscles in great number. 

This form develops as a morbid reaction after the intro- 
duction of instruments into the bladder, after catheterisation 
of a sensitive bladder, the dilatation of strictures, lithotripsy, 
etc. In addition to this, after acute inflammatory processes, 
especially upon the skin, the exanthemata. It may also 
develop ex-contiguo from acute cystitis after gonorrhoea. 
(/?) Acute Parenchymatous Nephritis Proper. 

This process may be ushered in by very turbulent symp- 
toms, or may occur without marked subjective symptoms, 
the latter occurring in cachectic, reduced individuals. 

Dropsy is the first symptom that causes uneasiness to 



ACUTE PARENCHYMATOUS NEPHRITIS. 1 59 

patient and physician. It appears as the characteristic 
oedema of the eyelids and face. Severe cases are accompan- 
ied by anuria and convulsions. The smaller the quantity of 
urine in 24 hours, the more intense is the attack, so that 
anuria lasting for some time nearly always results fatally. 

We find the following in the urine : 

The quantity is very much diminished, sometimes to 250 
c. c. Sp. gr. is usually increased, the reaction acid, the 
color brownish yellow and very turbid, frequently having a 
large deposit of cellular elements. 

The normal constituents are diminished. 

Of abnormal substances we find large quantities of serum- 
albumen and blood-coloring matter. The quantity of the 
former varying from 1, 5 to 6 per cent., so that the urine 
solidifies upon boiling. 

The sediment is usually of a brownish color and consists, 
principally, of coarse, sometimes long or spiral, casts of fi- 
brine, colored by the blood coloring matter. These some- 
times contain a great number of white or red blood corpus- 
cles (blood casts,) or brown epithelial cells of the uriniferous 
tubules (hemorrhagic). In other cases only debris of cells 
is found, surrounding the nuclei and adhering to or imbedded 
in the substance of the casts. In addition, we find cells 
from the tubules, many blood and lymph corpuscles and 
much detritus colored brown^by the blood coloring matter. 

This form is either a primary disease or a sequela to an- 
other acute disease. It is very frequent after the acute ex- 
anthemata, especially after scarlatina ; then after diphtheria, 
relapsing fever, phlegmonous inflammations, erysipelas and 
carbuncles; after the administration of preparations made 
from cantharides (cantharidin), as well as after the internal 



l6o EXAMINATION OF THE URINE. 

use of caustic remedies (corrosive sublimate). It is fre- 
quently observed after catching cold and after burns. After 
inflammatory rheumatism, cholera and during pregnancy it 
is not uncommon. 

This form also develops during the course of chronic 
parenchymatous nephritis. 

The prognosis is usually favorable but death may ensue 
from acute uraema or the form may be changed to a chronic 
inflammation. 

(y) Chronic Parenchymatous Nephritis. 

In this form also, the first symptom is dropsy. Fever is 
absent. 

The urine shows the following changes. 

As long as the disease continues to progress, and during its 
acme, the quantity is diminished; as soon as the inflamma- 
tion recedes, the quantity increases and in the stage of atro- 
phy may be very much increased. Its color is yellowish, 
often brownish yellow, turbid with cellular elements, forming 
an appreciable sediment. The reaction is acid and the sp. 
gr. usually diminished. 

Normal constituents, especially urea, are frequently dimin- 
ished. 

Albumen is found in considerable quantity, (}4 to i to 2 
% ) and blood coloring matter can be, commonly, detected. 

In the sediment are found dark, granular casts, also half 
granular casts, i. e., those that are granular in spots, the rest 
of the cast being made up of hyaline substance. There is 
also found granular epithelium of the kidney, red and white 
blood corpuscles and molecular detritus. 

In the stage of secondary atrophy, the quantity is very 
much increased, the sp. gr. very much diminished, the color 



CHRONIC PARENCHYMATOUS NEPHRITIS. l6l 

pale yellow, the urine turbid and having an appreciable sed- 
iment. When the atrophy affects boths kidneys, the excre- 
tion of normal constituents, especially of urea, is very much 
diminished. Albumen is present in small quantity, ^ to 
\ %. In the 'sediment are found granular masses of de- 
tritus, granular epithelium of the kidney and fragments of 
granular casts. 

In the minority of cases does this form arise from the 
acute form, generally it runs its course insidiously. Most 
frequently it arises from the acute form after scarlatina, and 
rheumatic processes, after profuse suppuration in the bones 
and also from the nephritis of pregnancy. 

The form that is chronic from the beginning, frequently 
develops from purulent processes in bone and the joints, as a 
result of syphilis, phthisis, malaria, scrofulosis and cachexia. 
Intemperance is also considered as cause. 

The prognosis is not very favorable. Cases occur in 
which, after dropsy and albuminuria has lasted for years, 
health is regained; but these are exceptions. After syphilis 
and malaria, as well as after osseous suppuration, a cure can 
sometimes be affected by the proper remedies. 
5. Interstitial Nephritis. 

The small amount of interstitial connective tissue present 
in the kidney may be subjected to hyperplastic proliferation 
or to destruction by suppuration. As a result we have two 
forms of interstitial nephritis : the hyperplastic and the 
purulent. 

(a) Hyperplastic Interstitial Nephritis — Cirrhosis 
of the Kidney — Contracted Kidney Proper. 

This disease rarely occurs in the young, most commonly 

in the old. 

21 



1 62 EXAMINATION OF THE URINE, 

It may exist for a long time and have developed fully 
without calling attention to its existence by symptoms. 
Dropsy rarely sets in and when it does, only in the last 
stage. 

A bounding pulse of high tension, as well as enlargement 
of the left ventricle of the heart are the usual symptoms of 
this form of kidney disease. 

Disturbance of sight is the most common complication of 
this disease, frequently being the first symptom that forces 
the patient to seek help. 

In the urine we find as follows : 

Its external appearance is that of a normal urine; clear, 
transparent, of a wine-yellow color. Its quantity is usually 
increased, but polyuria is not always the rule. The sp. gi*. 
is either normal, or, more commonly, reduced; the reaction 
is acid. 

The normal constituents are unaltered, as a rule. 

Albumen is found in moderate quantity Q — ^ %). 
It may disappear entirely — occurring especially when the 
patient is in bed, so that we find much less albumen in the 
morning urine than in that passed during the day. 

Macroscopically no sediment can be observed. Even with 
the microscope we frequently fail in finding anything abnor- 
mal. Only after careful and repeated examinations do we 
find a single hyaline cast, a blood corpuscle or epithelium 
from the kidney. 

The prognosis, when the diagnosis has been established, 
is usually unfavorable, but the course may be very long. 

The etiology is, as yet, dark. 

(b) Suppurative Interstitial Nephritis. 
This form may be of traumatic, idiopathic, pyaemic or 



INTERSTITIAL NEPHRITIS. 



I63 



metastatic origin. Frequently it originates in chronic pyeli- 
tis, in that the disease of the pelvis spreads to the connective 
tissue of the kidney and causes suppuration. This form is 
the usual termination of cases, in which surgical interference 
with the urinary organs has been had. For instance, after 
catheterisation of a paralytic bladder, after forcible dilatation 
of strictures, after lithotripsy, suppurative nephritis sets in. 

To this form, therefore, the name of "the surgical kidney'' 
was formerly given. 

Calculus of the kidney predisposes to this form, complica- 
ted by large abscesses of the kidney and pyonephrosis. 

We find the urine of the following description : 

Its color is yellow; it is turbid and scanty; its smell is 
frequently fecal; sp. gr. diminished, and reaction either neu- 
tral or alkaline. 

The normal constituents, especially urea, are diminished. 

Albumen is present in considerable quantity (j4 to 1^). 
Blood coloring matter is also present; not infrequently we 
find large quantities of carbonate and sulphide of ammonium. 

The sediment is copious and consists, principally, of pus, 
mixed with blood in greater or less quantity. Microscop- 
ically are found numerous bacteria, molecular detritus, epi- 
thelia from the kidney, and thick, dentritic casts made up 
of bacteria (Pyelo-nephritis parasitica — Klebs). 

If complicated by parenchymatous nephritis we also find • 
dark, granular, thick casts coming from the straight urinifer- 
ous tubules. 

The course of the disease is usually acute, and the termin- 
ation death. In chronic cases the larger abscesses break 
into the pelvis. 

Kidney abscesses can only be diagnosticated by means of 



164 EXAMINATION OF THE URINE. 

determining the quantity of pus discharged — easily accom- 
plished by collecting the urine in appropriate vessels. Pus 
appearing and disappearing suddenly, with the microscopic 
signs of necrotic kidney-tissue (glomeruli, uriniferous tu- 
bules) are the best indications for the existence of an 
abscess. 

4. — The Amyloid Kidney. 

Amyloid degeneration of the kidney is usually a symptom 
of a constitutional disorder. It occurs in profuse suppuration 
of bone, as well as in other suppurative processes that last 
for a considerable length of time. In pyonephrosis of one 
side the other kidney, frequently becomes amyloid. Scrofulo- 
sis, chronic tuberculosis, syphilis and malaria, favor the devel- 
opment of this form of disease. Occasionally it is found idi- 
opathically . Amyloid kidney complicated by parenchymatous 
nephritis is of frequent occurrence. 

This degeneration develops without producing any import- 
ant symptoms; but this rule can be laid down that an amy- 
loid kidney always secretes more urine, in 24 hours, than a 
normal kidney. The quantity, however, never becomes so 
great as in atrophy of the kidney. 

The urine is pale yellow, clear, and has a low sp. gr., an 
acid reaction and is without a macroscopic sediment. 

The normal constituents are usually diminished. 

Serum-albumen is constantly found in moderate quantity 
(from ^ to 1 or 2^). In addition there is found a consid- 
erable amount of globuline (Senator, Edlefsen) which may 
be considered as characteristic of this form of disease. 

In the sediment, frequently, no cellular elements are 
found, sometimes, delicate hyaline or waxy, shining, yellow- 






AMYLOID KIDNEY. 165 

ish casts. More rarely amyloid epithelium of the kidney is 
observed, which, in common with the casts, changes to a 
mahogany color upon the addition of an aqueous solution of 
iodine and upon the further addition of sulphuric acid be- 
comes violet. In the uncomplicated amyloid kidney, blood is 
not found in the sediment. 

The prognosis depends upon the disease at the bottom of 
the kidney disease. In syphilis and malaria we will, there- 
fore, have the best results. 

In the differential diagnc is of the various forms of true 
albuminuria, the following additional points must be taken 
into consideration. 

1 . If we find a sediment that can be detected with the micro- 
scope, that is made up of cellular elements, (blood, pus cor- 
puscles, casts, etc.,) we have either a parenchymatous 
nephritis or an interstitial suppurative nephritis. 

a. In parenchymatous nephritis we find epithelial, fibrine 
and granular casts, kidney epithelium, blood, and lymph- 
corpuscles. 

b. In suppurative interstitial nephritis we find pus, and 
blood corpuscles, bacteria, sometimes casts of bacteria, or 
short and thick, dark, granular casts. 

2. If the urine is clear, or cloudy with urates, and we find 
no sediment of cellular elements then we either have an 
hyperaemic kidney, an hyperplastic interstitial nephritis, or 
an amyloid kidney. 

a The hyperaemic kidney can be differentiated from the 
other two; by the diminished quantity of urine; by its dark 
color, its high sp. gr., and frequently by the abundance of 
urates it contains. 

b The amyloid kidney by its having globuline, and waxy 



1 66 EXAMINATION OF THE URINE. 

casts, and amyloid kidney epithelium. Clinically we find in 
amyloid degeneration (as well as in parenchymatous nephri- 
tis) dropsy, while in true atrophy this is the exception, and 
then occurs late in the disease. 

c In true atrophy we find hypertrophy of the heart and a 
bounding pulse, neither occuring in the parenchymatous 
nephritis and amyloid kidney. In the amyloid kidney we 
find enlargement of the liver and spleen (amyloid degener- 
ation). 

(B) Forms of Mixed Albuminuria, 

Mixed albuminuria is characterized by the urine always 
containing more albumen than corresponds with the quantity 
of pus present in the sediment. It includes those diseases 
of the pelvis of the kidney, which, when advanced, also 
attack the kidney, complicating pyorrhoea with true albumi- 
naria. 

As a proof that the papillary portion of the kidney is also 
affected in the pyelitic process, we refer to the occurrence of 
kidney epithelium in the sediment. We also find, when the 
process has continued for some time, that the pelvis is dilated 
at the cost of the papillary portion, the latter being more or 
less consumed. 

i. Pyelitis. 

Pyelitis frequently accompanies acute febrile diseases, also 
parenchymatous nephritis and (in the later stages), diabetes 
mellitus. The use of cubebs, copaiva, etc., is also sometimes 
followed by this form of disease. Renal calculi, parasites, 
tumors and tuberculosis in the pelvis are nearly universally 
accompanied by pyelitis. Ex contiguo, it or pyelo-nephritis 
develops from stasis of urine, as we find it in hypertrophy 



ACUTE PYELITIS. 1 67 

of the prostate, paralysis of the bladder, strictures of the 
urethra, etc. Pyelitis is also produced by compression of 
the ureters by tumors, exudations, the retroflexed or gravid 
uterus; as well as after gonorrhoea, mechanical irritations of 
the neck of the bladder and of the bladder itself, by surgical 
instruments, etc. 

We can distinguish two forms of pyelitis; the acute and 
the chronic. Besides, we frequently have points offered us 
for the diagnosis of pyelitis calculosa and tuberculosa in the 
sediment. 

Croupous and diptheritic pyelitis are usually caused by 
such grave diseases that the latter cover over the symptoms 
of pyelitis. 

(a) Acute Pyelitis. 

The best type is found after surgical interference with the 
urinary organs; in the course of acute inflammatory affections 
and after gonorrhoea. 

The quantity of urine is diminished moderately, the urine 
is dark, cloudy, has a high sp. gr. and acid reaction. Upon 
allowing to stand an appreciable deposit is found. 

Normal constituents are unchanged unless fever be present, 
then an increase in the urates and a diminution in the chlo- 
rides is observed. 

Albumen is always found in greater quantity than would 
correspond with the comparatively, small sediment of pus 
(io — %%)- Blood coloring matter is not constant and, 
when present, only in small quantity. 

The sediment is principally made up of mucus, mixed 
with more or less pus. The pus cells are round, frequently 
many united to form an oval or cylindrical plug. These 



1 68 EXAMINATION OF THE URINE. 

come from the papillae and frequently contain epithelium. 
We always find blood corpuscles : epithelium from the pap- 
illary portion of the kidney, of an ovoid or pear-shape form, 
is found in great abundance. Frequently two or three epithe- 
lial cells still adhere. Sometimes we find the epithelial cells 
tinged by blood coloring matter. 

Epithelial cells with one or two processes, arranged like 
shingles, usually called epithelium from the pelvis, is not at 
all characteristic for pyelitis. Indeed, this epithelium from 
the pelvis can hardly be distinguished from that of the blad- 
der. Besides, these cells are not always found in pyelitis, 
therefore the epithelium from the papillary portion of the 
kidney alone is characteristic for this form of inflammation. 

In acute pyelitis, epithelium from the kidney is always 
found in great abundance (10 cells and over in one field); in 
chronic pyelitis, on the other hand, it is not very abundant. 

Acute pyelitis, when the result of surgical interference, 
of acute inflammatory processes or gonorrhoea, usually allows 
of a favorable prognosis, in that a few weeks are sufficient 
to affect a cure. Sometimes the acute form becomes 

(b) Chronic Pyelitis. 

In chronic pyelitis the quantity of urine passed in 24 hrs. 
is always increased, so that polyuria may be put down as a 
characteristic sign of this disease. In severe cases, the 
quantity averages from 5 to 6 litres. The color of the tur- 
bid urine is pale reddish-yellow, sometimes a slight greenish 
shade. The sp. gr. is always diminished and the reaction 
acid. The deposit corresponds with the amount of pus 
present. 

Albumen is always found in larger quantity than could be 



CHRONIC PYELITIS. 1 69 

expected from the amount of pus present (} — y 2 %). 
Blood-coloring matter is not always present. 

The sediment has a greenish-yellow color; is flaky, does 
not adhere to the vessel, and is made up of pus, principally. 
Not infrequently, the pus cells are forked and branched, in 
contradistinction with other purulent processes in the urinary 
organs. They also form round, oval or long plugs (from 
the ductus papillaris) that are characteristic of chronic pye- 
litis. 

Epithelia are found in small number, and when suppura- 
tion is profuse they are entirely absent, probably on account 
of their becoming pus cells by endogenous growth. 

Blood corpuscles are not found in the ordinary chronic 
pyelitis, but when this is the result of renal calculi, tuber- 
culosis, tumors, or entozoa, they are never absent. 

The prognosis is rarely a favorable one. With us, it is 
usually a complication with the formation of calculi. The ter- 
mination in pyonephrosis, then perinephritis, and escape of 
the pus externally, more rarely into the intestine or bladder, 
is not uncommon, usually occurring in young or healthy 
individuals. In weak patients the pyelitis becomes inter- 
stitial nephritis finally terminating in chronic uraemia. 

(C) Pyelitis Calculosa. 

Renal calculi are formed, principally, by the deposit of 
uric acid in the kidney or pelvis, and therefore those stones 
that pass spontaneously are of a yellowish brown color, and 
made up of uric acid or urates. In addition, we have cys- 
tine (very rare) and the so-called secondary formation ; after- 
hemorrhage or long-continued suppuration, by the deposit of 
the earthy phosphates, as the origin of renal calculi. Oxalate 
22 



170 EXAMINATION OF THE URINE. 

of calcium, very rarely is the primary deposit, but frequently 
forms layers. 

The most common cause for the formation of renal calculi 
is the deposit of uric acid, on account of its absolute or com- 
parative excess. This is favored by the acidity of the urine, 
increasing with its concentration, producing those rough 
crystals of uric acid which nearly always form the nucleus of 
these calculi. The predisposition to calculi is to be sought 
for in concentrated, highly acid urine, rich in uric acid, 
especially when it crystallizes in the rough or lance-shaped 
crystals. 

The beginning of this disease can be diagnosticated when, 
besides the properties of the urine already enumerated, we 
find mild albuminuria (hyperemia of the kidney) and single 
blood corpuscles in the sediment. The albuminuria is only 
temporary, and appears when the urine is either very much 
concentrated or contains very much uric acid in excess. 

The presence of large concretions can be diagnosticated 
by the occurrence of parenchymatous hemorrhages. The 
urine is reddish brown or coffee colored, especially after 
bodily exercise. 

If the calculi are not passed then there arises pyelitis — 
pyelitis calculosa. 

This may be found either in a mild or severe form. 

The mild form occurs with calculi of small diameters, and 
frequently has characteristic elements in the sediment; whilst 
the severe form can only be differentiated from chronic pye- 
litis by the presence of blood corpuscles in the sediment. 
The latter form is usually observed with large calculi, form- 
ing a focus for pyonephrosis, paranephritis and emptying of 
the pus. 



PYELITIS CALCULOSA. 171 

The milder form shows the following changes in the urine : 

The quantity of urine is usually normal, sometimes dimin- 
ished, never increased. The color is dark, its sp. gr. normal 
or increased, reaction very acid, the urine frequently having 
a considerable sediment. 

Uric acid is present in excess (uric acid present in the sed- 
iment, and the detection of a layer of urates with the nitric 
acid test). 

Albumen is found in from ^ to ^^, always a greater 
quantity than would correspond with the amount of pus pres- 
ent. Blood-coloring matter is always present, if only in 
small quantities. 

The sediment is made up, principally, of lance-shaped uric 
acid crystals (cystine, oxalate of lime), mixed with curdled 
pus. Besides, we find numerous red blood corpuscles (espe- 
cially microcytes) and epithelia from the kidney. 

The diagnosis is made positive by the clinical signs and by 
the absence of calculi upon sounding the bladder. 

Renal calculi only when small offer a favorable prognosis. 
When these are large or branched the prognosis is always un- 
favorable, or at least doubtful. The greater the suppuration 
and the longer it lasts the more unfavorable does the progno- 
sis become. 

The disease is usually unilateral. 

(Z>) Pyelitis Tuberculosa. 

As a rule, pyelitis tuberculosa is a symptom of general 
tuberculosis or tuberculosis of the uro-genital apparatus. For 
this reason we frequently find it complicated by chronic par- 
enchymatous affections of the kidney (nephrophthisis — ne- 
phritis ulcerosa). In those cases in which tuberculosis of the 



172 EXAMINATION OF THE URINE 

pelvis and kidney, both, exist, we find large, waxy casts, 
much molecular detritus, pus and blood corpuscles and kid- 
ney epithelium in the sediment. A great quantity of al- 
bumen is found in the urine. 

Simple pyelitis tuberculosa, on the other hand, produces 
the following changes : 

The quantity of urine is not increased very much; its color 
is yellow, frequently brownish red (on account of the admix- 
ture of blood). It is always cloudy, has a normal or dimin- 
ished sp. gr. and an acid reaction. The sediment is grayish 
or brownish, and flocculent. 

The excretion of the normal constituents is not very much 
changed. 

Albumen is found in from & to }£%. Blood-coloring mat- 
ter can always be detected. 

The sediment consists of pus, principally, and a small 
quantity of blood; in addition, we find kidney epithelia and 
molecular detritus, mixed with bacteria, the latter united so 
as to form spherical or cylindrical bodies. 

The presence of blood corpuscles, usually denotes an ulcer- 
ative process in the pelvis, and will, therefore, be observed 
both in the urine passed during the day and during the night; 
in pyelitis calculosa, on the other hand, the urine passed in 
the morning, or whilst the patient is at rest, contains much 
less blood than that passed during the day or after exercise. 
In tubercular pyelitis the desire to pass water is not accom- 
panied with as much pain and is not so frequent as in cal- 
culous pyelitis. In addition, the usual symptoms of lithiasis 
are absent. 

The diagnosis is much easier if we find hard, plastic exu- 
dations in the testicles, scrofulous cicatrices, enlargement of 



PYELITIS TUBERCULOSA. 1 73 

glands, or other diseased processes in bone, deep fistulae in 
ano, etc. 

When general tuberculosis is present, the prognosis is al- 
ways unfavorable. In tuberculosis of the genital organs, 
when affecting young and healthy individuals, improvement 
or comparative health may be secured, as after the removal of 
a tubercular testicle, for example. 

In echinococci we sometimes find pyelitis, which cannot, 
however, be distinguished from any ordinary pyelitis. It is 
only when the tumor has emptied into the pelvis that we find 
the characteristic cysts in the sediment, besides single scoli- 
ces with a double row of hooklets or remnants of these and 
single hooklets. 

In bilharzia haematobia the pyelitis accompanies the cystitis. 
It is always complicated by copious parenchymatous hemor- 
rhages. In the sediment we find numerous blood and pus- 
corpuscles, kidney and bladder epithelia, and coagula of fi- 
brine enclosing the characteristic ova of the bilharzia. 
There is also present much albumen and blood-coloring 
matter, dissolved. 

Para- or perinephritis can not be diagnosticated from the 
urine as the latter, even in a severe attack, frequently pro- 
duces normal urine. 

2. HEMATURIA. 

Strictly speaking, this is a symptom and not a disease, but 
as it accompanies so many diseases and these diseases can 
not always be determined, we therefore having to be satisfied 
with the diagnosis * ' haematuria from unknown causes/' we 
have thought it best to treat of it here. 

Hemorrhages from the urinary apparatus may be divided 
into three classes : 



174 EXAMINATION OF THE URINE. 

a Hemoglobinuria (haematinuria of Vogel) ; 

b Parenchymatous hemorrhage, and 

c Copious hemorrhage, produced by the rupture of large 
blood vessels. 

i. Hemoglobinuria is characterized by a reddish brown, 
brownish-black urine, from which, even after it has stood for 
hours, no red deposit forms. It retains its uniformly reddish 
brown color, because the blood-coloring matter is dissolved. 
The reaction is usually acid and sp. gr. diminished. It con- 
tains much haemoglobin e and methaemoglobine. In the sedi- 
ment hemorrhagic epithelia and brown molecular detritus 
are sometimes found. Blood corpuscles are not present. 

2. In parenchymatous hemorrhage, we also observe a red- 
dish brown, frequently coffee-colored urine, which will retain 
its color for a long time, but deposits a reddish brown sedi- 
ment, consisting of red blood corpuscles. Its reaction is 
acid, its sp. gr. varies, and it has dissolved haemoglobine, 
more or less altered. 

For the parenchymatous hemorrhage the sediment is char- 
acteristic. There are found, in it, blood corpuscles of vari- 
rious sizes. Frequently normal, round corpuscles, with 
depressions, cannot be seen at all, but in their stead they are 
globular, spherical and colored brown. Frequently they are 
entirely colorless, looking like small rings. 

In the same field we will observe very large ones, others 
only are half or one-quarter as large as normal, and some as 
small as dust. 

These microcytes, which, in modern times, have been 
observed so frequently in the blood of patients, have long 
ago been known to exist in the urine from parenchymatous 
hemorrhage, and have been considered as characteristic for it. 



HAEMATURIA. 1 73 

3. In the hemorrhage coming from the rupture of large 
vessels, the urine is either dark reddish-yellow or red, similar 

to venous blood. The reaction is, commonly, neutral or 
alkaline. The sp. gr. varies. The urine usually contains 
traces of coloring matter in solution; it is only when much 
ammonium carbonate is present, a rare oc irrence, that 
considerable quantities are dissolved. 

Usually the urine from rupture of large vessels deposits its 
entire blood, after standing for several hours, in the form of 
a copious red sediment in which the blood corpuscles appear 
of their normal color, size and shape. 

Albumen can always be found in this kind of urine. 

These three forms of hemorrhage may originate in the 
bladder,the pelvis or the kidney and we are not always so 
fortunate as to be able to state where the blood comes from. 

1. We seek to utilize the reaction for the differential 
diagnosis. Generally, it is accepted that, in hemorrhage 
from the kidney, it is acid; from the bladder, alkaline. But 
this is not always the case; indeed, the one can only occur 
when hemorrhage is complicated by purulent catarrh of the 
pelvis or bladder. Here the reaction on litmus is not de- 
cisive, for, in large hemorrhages, we find the alkalinity 
of the blood neutralizing the acidity of the urine, and we 
may have an alkaline rea ven if the blood comes from 

the kidney. The internal administration of alkalies could 
be sufficient to make the urine alkaline or the amount of pus 
formed in the pelvis of the kidney, with its alkaline reaction, 
could be sufficient to neutralize the urine — in these cases we 
would have an alkaline reaction and yet the hemorrhage not 
from the bladder. 

On the other hand, it cannot be denied that hemorrhages 



176 EXAMINATION OF THE URINE. 

from the bladder occur in which the reaction of the urine is 
acid. This is always the case when purulent catarrh of the 
bladder is absent and when the hemorrhage is not very great. 

Of greater importance than the reaction is the detection 
of carbonate of ammonium. If this is present in sufficient 
quantity, then the likelihood of hemorrhage from the blad- 
der becomes greater, especially if, at the same time, we find 
crystals of the triple phosphate in the sediment. 

2. The color of the urine is of greater importance in this 
respect. The older practitioners have always associated the 
reddish brown or brownish black color of the urine with 
hemorrhage from the kidney and the light red with hemor- 
rhage from the bladder. This, however, is not altogether 
correct. The dark colors are produced by decomposed 
haemoglobine (methaemoglobine), and can only occur when 
blood has been intimately mixed with urine and retained 
within the body for some time. This occurs in parenchyma- 
tous hemorrhages : the blood is gradually mixed with the 
urine; the blood corpuscles remain, for a long time, in a 
comparatively large quantity of fluid containing substances 
undergoing retrograde metamorphosis; the constituents of the 
urine, therefore, have sufficient time to exert their destructive 
influence upon the red corpuscles, converting haemoglobine 
into brown methaemoglobine. 

For this reason the urine in parenchymatous hemorrhages, 
even when they come from the bladder (cancer), takes upon 
itself the brown tints. 

It is an entirely different matter when the hemorrhage is 
produced by the rupture of larger vessels (haemorrhoids of 
the bladder). Here a large quantity of blood is suddenly 
introduced into the bladder and suddenly dilates it. This is 



HAEMATURIA. 1 77 

followed by tenesmus and the blood is passed before the 
urine has had time to act upon the haemoglobine. 

As hemorrhages from the bladder are, as a rule, produced 
by rupture of large vessels, and those from the kidney 
are parenchymatous, we can readily understand how the 
different color of urine becomes a very valuable diagnostic 
point. 

3. The specific gravity is of importance in that, in hem- 
orrhage from the kidney or pelvis, disease is usually present 
that produces polyuria; therefore low sp. gr., while in hemor- 
rhages from the bladder, there is, as a rule, no change in 
this respect. 

4. If coagula are present they sometimes point positively 
to the seat of the lesion. 

If the coagula are soft and have the color and consistency 
of fresh, coagulated blood, then they have not existed for a 
long time; but if they are discolored, then they are old and 
have been retained for some time. Short, rod-like coagula 
sometimes come from the dilated pelvis (Simon) and are 
found after hemorrhages from the kidney ; formerly they 
were considered as concrements made up of pure fibrine 
(Heller). 

Large, irregular, shred-like coagula, are said to come from 
the bladder. We must call especial attention to the fact 
that the rod-like coagula alone can be considered of diagnos- 
tic value. If they are present we can state positively that 
the seat of hemorrhage is above the ureters, for the long 
coagula are molds of the ureters. The irregular coagula, 
on the other hand, are not at all characteristic. They may 
be produced in the pelvis as well as in the bladder. 

It may even happen that fluid blood, poured out in the 
kidney, passes into the bladder and coagulates there. 
23 



178 EXAMINATION OF THE URINE. 

Moreover, coagula are not constant in hemorrhages. Pa- 
renchymatous and copious hemorrhages will rarely produce 
coagula. They occur when the blood comes from vessels 
of small calibre. 

5. The most important aid to diagnosis is afforded by the 
microscopic examination of the sediment. 

For parenchymatous hemorrhages from the kidney, the so- 
called blood casts and hemorrhagic epithelium of the kidney 
are characteristic. After copious hemorrhages, however, 
(if occurring from large vessels,) these are not found. It is 
highly probable that kidney epithelia are present but they 
are covered over by the great number of blood corpuscles, 
and cannot be detected. 

Hemorrhages from the bladder are frequently not at all 
characterized by Jthe sediment. Sometimes we find an in- 
crease in epithelia from the bladder and crystals of triple 
phosphates. 

After the description of the microchemical characteristics 
of hemorrhages from the urinary apparatus,we proceed to 
discuss the diseases in which they occur and also seek new 
diagnostic points. 

I. Haemoglobinuria (with or without methaemoglobinuria,) 
occurs in the hemorrhagic diathesis, scorbutus, congestive 
chills, in putrid typhus fevers, in fact, in all diseases that are 
accompanied by blood dissolution; after the inhalation of 
arsenetted hydrogen, carbonic acid gas and other similar sub- 
stances. Also, after transfusion with animal blood do we 
find haemoglobinuria, especially in those cases in which 
much blood has been used. 

II. Parenchymatous Hemorrhages may come from any part 
of the urinary apparatus. 



HAEMATURIA. 1 79 

(a) Hemorrhages from the kidney, in addition to the 
diseases before enumerated, usually associated with haemo- 
globinuria, are found : 

1. Occasionally, in acute febrile diseases, especially in 
the exanthemata, where the hemorrhage represents a higher 
degree of hyperaemia. 

2. In the majority of cases of chronic parenchymatous 
nephritis. 

3. As a rule, in atheromatous degeneration of the vessels 
of the kidney. 

4. In thrombosis of the renal vein, occurring in general 
cachectic conditions; in puerperal fever, with phlebitis of the 
femoral and uterine veins; furthermore, accompanying 
serious injuries of the kidney, sometimes with traumatic ne- 
phritis; finally, as a result of compression by tumors in the 
neighborhood of the hilus. 

In infants suffering with intestinal catarrh, thrombosis of 
the renal veins sometimes occurs. According to O. Pollak 
this is recognized by the children becoming jaundiced, by a 
great diminution of urine following, and in that we find in 
the sediment, blood casts, blood corpuscles and hemorrhagic 
kidney epithelium. 

Hemorrhages from the kidney are furthermore observed : 

5. Constantly in renal calculi, when severe pyelitis has 
not developed. The sediment, besides those elements char- 
acteristic of calculi, contains blood corpuscles and kidney 
epithelia. 

6. In cancer of the kidney; besides the hemorrhage, 
nothing suspicious is found. We have never found cancer 
cells nor cancer tissue in the sediment, but such a thing may 
occur when the cancer grows into the pelvis of the kidney. 



l8o EXAMINATION OF THE URINE. 

In small children there are observed large tumors of the size 
of a fist in the kidney without our being able to detect a sign 
of albuminuria. Haematuria, therefore, is not always pres- 
ent in tumors of the kidney, but is a very common symptom. 

7. In nephrophthisis or in caseous inflammation of the 
kidney, of the pelvis, and the ureters. In addition to the 
microcytes, we find, in the sediment, kidney epithelium, pus 
cells, much molecular detritus, numerous vibriones and cocci; 
sometimes waxy casts, mixed with casts made up of bacteria. 

{b) Hemorrhages from the bladder are observed : 

1. In stone in the bladder and in catarrhal ulcers at the 
neck of the bladder. Haematuria is of a mild nature. 

But in both cases microcytes can not be detected in the 
sediment. All the red corpuscles are of normal size. If 
catarrh of the bladder is also present then we find its 
characteristic urine. 

Haematuria in vesical calculus becomes more intense after 
exercise and ceases when the patient is in bed. Haematuria 
in catarrhal ulcers, situated at the neck of the bladder, 
usually originating in gonorrhoea, takes place at the end of 
micturition when the sphincter of the bladder begins to con- 
tract. 

2. In papilloma and villous carcinoma of the bladder, 
parenchymatous hemorrhages also arise from the papilloma- 
tous proliferations of its mucous membrane. Not infre- 
quently we find in the sediment necrotic papilla tissue, 
which facilitates diagnosis. (See chapter on cancer.) 

(c) Parenchymatous hemorrhages throughout the entire 
apparatus occur. 

1. Sometimes, after the emptying of a paretic or para- 
lyzed bladder with the catheter. If the entire urine is 



HAEMATURIA. l8l 

drawn off, a quantity of which' probably has remained for 
years in the bladder, because the paretic bladder was un- 
able to pass it, an hyperaemia ex-vacuo must occur, which be 
comes the more intense the thicker the muscular coat of the 
bladder is, and the greater its inability for contraction. At 
the same time the pressure in the kidney is also changed, 
producing a parenchymatous hemorrhage. 

2. They are also observed in Egypt, as a result of the 
bilharzia haematobia. Emboli of the vessels of the mucous 
membrane are produced by the ova of the distoma haema- 
tobium. The sediment is characteristic for this disease. 

III. Large hemorrhages after the rupture of vessels only oc- 
cur in tumors and varicose vessels at the neck of the bladder. 

In tumors they only occur when the cancer has existed 
for a long time and begins to ulcerate. In the so-called 
haemorrhoids of the bladder the bleeding is very profuse, 
coming on very suddenly and, after i or 2 days, rendering 
the patients very anaemic. It usually lasts for several days, 
then leaves the patient perfectly well, returning after months 
or years. In the sediment we only find blood corpuscles 
of normal size. 

In diphtheretic and croupous processes of the bladder, 
occurring after dissolution of the blood, we also find blood 
in the fetid, ichorous and alkaline urine. 

3. Cysto-Pyelitis and Pyelo-Cystitis. 

Under this designation, a purulent catarrh affecting pelvis, 
ureters and bladder is understood. If the pelvis is princi- 
pally affected it is cysto-pyelitis, but if it is the bladder then 
we term it pyelo-cystitis. 



l82 EXAMINATION OF THE URINE. 

By characteristic signs we determine whether it is the 
bladder or the pelvis that is principally affected. 

If pyelitis prevails, then polyuria will usually be present ; 
the urine will be of neutral or faintly alkaline reaction ; sp. 
gr. will be low, and the purulent sediment will not adhere to 
the glass. Albumen will be present in greater quantity than 
would correspond with the amount of pus present, and in the 
sediment we find pus corpuscles, kidney and bladder epithe- 
lium and crystals of the triple phosphate. The pus corpuscles 
are well preserved and sometimes united to form plugs. 

If cystitis prevails, polyuria is absent ; the urine is very 
alkaline, its sp. gr. normal or only slightly diminished. The 
sediment is pasty and adheres to the vessel. Albumen is 
present to corespond with mixed albuminuria and consider- 
able quantities of ammonium carbonate can be detected. 

In the sediment the pus corpuscles are very much swollen, 
lying between a great number of crystals of the triple phos- 
phate; in addition we find single kidney and bladder epithelia. 

Cysto-pyelitis and pyelo-cystitis occur frequently in stric- 
ture of the urethra, in hypertrophy of the prostate and in 
paresis or paralysis of the bladder. 

In addition, from cystitis or pyelitis, cysto-pyelitis and 
pyelo-cystitis may easily originate by direct continuity of the 
tissues. It is not rare that cystitis alternates with pyelo-cystitis, 
and pyelitis with cysto-pyelitis. 

The prognosis depends upon the cause and the prevailing 
disease. 

(c) Forms of False Albuminuria. 

False albuminuria is distinguished from the other forms by 
the fact that true albumen is present in quantities corre- 



CYSTITIS. 183 

sponding with the quantity of blood or pus present in the 
urine. The albumen that is detected is albumen from pus 
or blood serum, and these disappearing suddenly, as after 
the rupture of an abcess or varix into the bladder, the albu- 
men will also be gone. 

We have seen from whence true and mixed albuminuria 
always comes : by exclusion we can arrive at the seat of 
lesion producing false albuminuria ; the bladder, urethra and 
their adnexa. 

1. Cystitis — Catarrh of the Bladder. 

We have acute and chronic cystitis, and of each, three de- 
grees. 

In cystitis of the first degree, the urine contains neither 
pus nor albumen, but simply an increased amount of mucus 
and has an acid reaction. In the second degree it contains 
albumen and pus, has an alkaline reaction and a mucilagi- 
nous greenish sediment. The third degree is characterized 
by ichorous, fetid urine, the presence of much albumen, pus 
and blood, and a marked alkaline reaction; it occurs as a 
result of ulcerative processes in the bladder, and, not infre- 
quently, has suppurative nephritis as complication. 

In catarrh of the bladder the urine usually has an alkaline 
reaction, and many practitioners, even to-day, diagnosticate 
this form of disease by means of litmus paper. 

This test is usually a reliable one, but then there are cases 
of cystitis in which the urine has an acid reaction. But this 
is only true for the urine when passed recently, for in a few 
hours it becomes alkaline. 

(a) Acute catarrh of the bladder of the first degree presents 
the following : 



184 EXAMINATION OF THE URINE. 

The quantity of urine is not diminished. The urine has a 
normal or dark wine-yellow color and is turbid. The reaction 
is faintly acid, but changes in a few hours to alkaline. There 
is considerable sediment, very cloudy and not solid. 

Excretion of normal constituents is unchanged. 

Carbonate of ammonium is the only abnormal substance 
that can be detected. 

The sediment consists principally of cloudy mucus. Mi- 
croscopically we detect mucus corpuscles (young cells) 
and epithelia from the bladder, in small quantity. After 
a few hours small numbers of the crystals of the triple phos- 
phate are found. 

This form represents a diseased condition of the mucous 
membrane, as it occurs in prostatitis after gonorrhoea and 
after the introduction of instruments into the bladder and 
urethra. 

(b) Chronic Catarrh of the first degree is characterized by 
a wine-yellow, exceedingly cloudy urine, whose sp. gr. is 
normal and whose quantity is not increased. The reaction 
of the fresh urine is acid but quickly becomes alkaline. The 
sediment is considerable and cloudy. Sometimes the urine 
has a peculiar penetrating odor and the cloudiness, consist- 
ing principally of bacteria, is never completely deposited. 

The only thing abnormal in the solids is the presence of 
carbonate of ammonium in small quantities. 

The sediment is the same as that of the preceding form, 
with the addition of bacteria. 

This form of urine is found in patients that are forced to 
use the catheter in order to empty the bladder ; in hyper- 
trophy of the prostate gland, paresis of the bladder and 
similar obstructions to the passage of urine. In elderly 






CYSTITIS. 185 

women, that have given birth to many children, or that 
suffer from any diseased condition of the uterus, this con- 
dition is nearly always present. 

(c) Acute catarrh of the second degree is distinguished from 
the preceding forms principally by the amount of pus 
present in it. 

The urine has a dark wine-yellow color and is turbid. 
The turbidity is produced by mucus and pus, while in the 
catarrh of the first degree, the cloudiness is produced by 
mucus alone. The quantity and sp. gr. are normal, but the 
reaction is alkaline. The sediment is greenish yellow and 
adheres to the vessel in which the urine is preserved. 

The normal constituents are only changed in that part of 
the urea is changed to carbonate of ammonium. 

Albumen is found in quantities to correspond with the 
amount of pus present, and carbonate of ammonium is 
present in great quantity. 

The sediment consists of alkaline pus mixed with crystal- 
line and amorphous earthy phosphates. With the micro- 
scope are detected blood-corpuscles, urate of ammonium 
and very much epithelium from the bladder. 

This form occurs in hypertrophy of the prostate ; after 
lithotripsy of large and hard calculi ; after the dilatation of 
strictures; after catheterisation or the introduction of other 
instruments. Furthermore, after gonorrhoea and acute pros- 
tatitis, and, finally, after catching cold, especially depending 
upon the action of cold and moisture. In women, after 
operations upon the uterus or vagina, in perimetritis and 
pericystitis. Sometimes this form is also observed after the 
administration of cantharides or other medicaments. It is 
said that the drinking of badly -fermented, so-called * ' young " 
beer will also produce this disease. 
24 



1 86 EXAMINATION OF THE URINE. 

(d) Chronic Catarrh of the bladder of the second degree 
produces urine that is nearly identical with that just described. 
In addition, as in the chronic catarrh of the first degree, we 
find bacteria in the urine. 

In the sediment the pus corpuscles are very much swollen, 
their outlines indistinct and the nuclei distinctly visible : fre- 
quently, the latter alone are observed imbedded in an homo- 
geneous, granular mass. 

Sometimes the pus is entirely dissolved in the alkaline 
urine, giving to the latter a syrupy, tenacious consistency. 

This form is found in hypertrophy of the prostate gland, 
in paresis of the bladder and in diseases causing obstruction 
to the passage of urine. 

(e) Acute catarrh of the third degree includes those pro- 
cesses that have been called cystitis, parenchymatous and 
pericystitis. 

Although we are not always able to diagnosticate these 
diseases from the urine, yet diagnosis is very much facili- 
tated by its examination. 

If the quantity of pus is very variable then we can some- 
times deduce the rupture of an abscess of the bladder. 

The urine presents the same changes as that of the second 
degree, with the exception that the purulent sediment does 
not adhere to the vessel and that it contains many blood 
corpuscles. 

(/) Chronic Catarrh of the third degree is a purulent catarrh 
complicated by an ulcerative process in the bladder. 

The urine is of a dirty brownish-yellow color, has a fecal 
smell, its reaction is strongly alkaline and the turbidity is 
produced by pus, mucus and bacteria. The sp. gr. is di- 
minished; the sediment of the same color as the urine and 
adheres to the vessel. 






CYSTITIS. 187 

The normal constituents are diminished : 

Of abnormal constituents we find a great quantity of al- 
bumen, blood coloring matter, ammonium carbonate and 
ammonium sulphide. 

The sediment consists of ammoniacal pus mixed with 
blood and earthy phosphates. With the microscope we find 
large quantities of bacteria, molecular detritus and single 
epithelia from the bladder. 

This process occurs in paralysis of the bladder and great 
hypertrophy of the prostate gland. It is easily complicated 
by pyelo-nephritis or suppurative nephritis. Symptoms of 
uraemia or ammonaemia close the scene. 

Similar urine is found in tuberculous ulcers of the bladder 
and in diptheria. 

In croupous affection of the bladder, as they sometimes 
occur, especially in women, large reddish-white membranes, 
consisting of fibrine as discharged with the urine. 

In practice, the symptoms of spasm of the bladder are 
frequently confounded with those of cystitis. Only the ex- 
amination of the urine will make this diagnosis easy. 

In Spasm of the Bladder the urine is usually clear, in case 
it is turbid, it is due to the earthy phosphates, amorphous 
and about to be deposited. Besides, the urine is pale and 
has faintly acid or neutral reaction. 

In boiling, the urine becomes cloudy, earthy phosphates 
and carbonates are deposited, that are readily soluble upon 
the addition of a small quantity of acetic acid. Sometimes 
carbonate of sodium can be detected. 

Albumen, pus, carbonate of ammonium, etc., are not 
present in spasm of the bladder. 

In the sediment are found calcium carbonate, crystalline 



1 88 EXAMINATION OF THE URINE. 

calcium phosphate and amorphous earthy phosphates. Crys- 
tals of the triple phosphate and epithelial cells from the 
bladder are absent. 

2. Neoplasms in the Bladder. 

Having discussed the varieties of hemorrhage from the 
bladder under the head of "Haematuria," it now becomes 
necessary to state, in detail, the uroscopic signs found in the 
various kinds of neoplasms of the bladder. 

We find the following : 

(a) Simple fibrous polyps, with a pedicle and hanging 
into the bladder; they are very rare. 

(b) Medullary sarcomata ; also very rare. 

(c) Epitheliomata and 

(d) Villous, or vascular tumors. 

i. Fibrous polyps produce symptoms of catarrh of the 
bladder of the second degree, and only when they ulcerate 
do we find blood in the sediment. 

We are not able to diagnosticate this form of disease, as it 
does not cause any characteristic histological elements to ap- 
pear in the sediment. 

2. Medullary sarcomata produce a similar urine, except 
in the later stages, when they are followed by catarrh of the 
third stage. The urine is sometimes of a greenish-brown 
color and has a very offensive odor. In the sediment is 
found much molecular detritus, but nothing characteristic. 

3. Epitheliomata usually develop very slowly, sometimes 
producing a catarrh of the second, sometimes of the third 
degree. The sediment always has more or less of a bloody 
tint. 

Upon microscopical examination we sometimes find pe- 
culiar, numerous small epithelial cells (in addition to blood 



NEOPLASMS. 189 

and pus corpuscles) that sometimes are found in equally- 
great numbers with the pus cells. 

They are small, round or oval, not unlike kidney epithe- 
lium. Sometimes they are caudate or have two or three 
small processes. The nuclei occasionally are very large and 
several are visible in one cell. Ten or twelve of these cells 
adhere and then form ragged epithelial structures. 

Although the diagnosis of epithelioma is not justified by 
this appearance, any suspicion that may be had regarding 
the nature of the disease is very much strengthened by this 
microscopical appearance. 

4. The papillary or vascular tumors can always be diag- 
nosticated from the urine. 

Two kinds of this form of tumor can be recognized: 1, 
the papillary proliferations (papilloma) of the mucous mem- 
brane of the bladder, and, 2, the true villous cancer. 

Parenchymatous hemorrhages are common to both forms; 
both forms are sometimes accompanied by catarrh of the sec- 
ond degree, sometimes of the third ; in the first form only the 
papillomatous proliferations may necrose and fall off, the 
patient again being restored to health ; in the second ca- 
chexia is developed and the patient dies. 

The villous cancer is made up of a mass more or less soft, 
similar to medullary sarcoma tissue, growing into the pos- 
terior, inferior wall of the bladder, so that a thickening or 
tumor can be felt by the finger when introduced into the 
rectum. Upon this tumor, forming the surface, the peculiar 
villous tissue, which is made up of ecstatic capillaries and a 
covering of epithelium, proliferates 

Papilloma of the bladder, on the other hand, is confined 
to the mucous membrane of the bladder. A tumor or thick- 



I90 EXAMINATION OF THE URINE. 

ening of the walls of the bladder can not be felt from the 
rectum. 

We cannot differentiate these two forms from each other 
by means of examining the urine — indeed, a villous cancer 
frequently develops from a papilloma. There are a few 
points that may make the differential diagnosis possible. 

If we find villi, well developed, and covered over with a 
thin layer of epithelium, it is usually considered that a pap- 
illoma is present; if the layer of epithelium is so thick that 
the vessels within the villus can no longer be distinctly seen, 
then we assume that a cancer is present. 

But this is of less importance than the detection of intu- 
mescence in the walls of the bladder and the presence of a 
cachexia. 

On account of this difficulty of diagnosis it seems fit to 
discuss both forms together. 

In these tumors the urine presents the following changes: 

The quantity is not increased, the sp. gr. is normal. The 
color is that of parenchymatous hemorrhages, and the tur- 
bidity is produced by blood and pus corpuscles. The re- 
action is, usually, faintly acid; only when the tumor becomes 
larger and the cystitis more pronounced, followed by abun- 
dant suppuration, the reaction becomes alkaline. The sedi- 
ment is flaky, brownish or brownish-red, and contains fibres 
or small ragged bodies of the same color. 

The consistency of the urine is that of a thin fluid, but 
temporary fibrinuria is sometimes observed. This is the only 
disease that produces fibrinuria in our zone. 

When passed, in these cases, the urine is thin, but in a few minutes 
congeals to a gelatinous mass that cannot be poured from the vessel. 
After shaking for some time the urine again becomes fluid and may then 



NEOPLASMS. 191 

be used for examination. Its color is not always blood-red, sometimes 
only pale reddish-yellow. 

It is always accompanied by tenesmus. The fibrinuria can be ex- 
plained by assuming that the blood vessels in the muscular layer are 
compressed by the violent cramp-like contraction of the muscular 
suoscance. The veins are compressed more than the arteries, and sta- 
sis takes place in the vessels of the villi. If the pressure is very 
great, rupture takes place, if not, the plasma of the blood is forced 
out, which afterward coagulates on account of the great amount of 
fibrine contained in it. 

The normal constituents are unchanged : 

Albumen and blood-coloring matter are frequently found 
in great quantity. We must especially notice the fact that 
the quantity of albumen is greater than would correspond 
with the quantity of pus and blood, due probably to increased 
pressure in the vessels. We must be careful not to make 
the diagnosis of disease of the kidney, in these cases, unless 
undoubted casts are found in the sediment. Small pieces of 
villi are apt to mislead the inexperienced observer, being 
looked upon as casts. 

Ammonium carbonate can not always be detected. 

When much blood or pus are present it becomes very dif- 
ficult to see the cancer tissue — indeed, it is only by chance 
that particles are then observed. It is best, therefore, to 
select a comparatively clear and colorless urine for examina- 
tion. Let the urine deposit its sediment and from this fish 
out the reddish flakes for microscopical examination. 

The sediment consists either of blood only, or of blood 
mixed with pus. The blood is found in a fluid condition, 
but coagula are always found. The latter can be distinguished 
from the villous tissue by their dark red color. Not infre- 
quently we find villous tissue inclosed in these coagula. 



192 EXAMINATION OF THE URINE. 

The blood corpuscles are the same as in parenchymatous 
hemorrhage. 

The villous tissue may present itself in the most manifold 
forms, according to the reaction of the urine. We are disap- 
pointed if we think to find it as beautiful and characteristic 
as it is represented in text-books. Villous tissue, entire, living, 
does not occur in urine; it is only when we introduce a cath- 
eter that we occasionally find it adhering to the openings 
of the instrument. We usually find necrotic tissue in the sed- 
iment and this may vary very much in form. 

In the beginning of the disease we find characteristic and 
beautiful villi [see fig. 14.]. The villi being necrotic and 
their blood vessels ruptured, we rarely find blood corpuscles 
whole in their interior. Beautiful villous tissue is found 
especially in papilloma of the bladder. 

But we are not always so fortunate as to find this. Especi- 
ally in cancer, with thick epithelial covering, it becomes 
impossible to discover the villi. The epithelial layer is be- 
ginning to necrose and the individual cells can no longer be 
discovered. It is infiltrated by pus and blood corpuscles 
and alive with bacteria. Sometimes branched structures 
are observed in this detritus that represent the stroma and 
the blood-vessels. 

These histological points are not sufficient for diagnosis; 
but we find with the microscope, other bodies that make the 
diagnosis positive. They are as follows : 

If we examine the necrotic tissue with high powers, we 
will find parts of the epithelial layer of a brownish color. 
If the urine is of acid reaction, a closer examination will re- 
veal that these spots are made up of crystals of haematoidine. 
If a drop of fuming nitric acid is allowed to flow under the 



CALCULI OF THE ELADDER. 1 93 

thin slide, a change of color from green, blue to violet will 
take place. These crystals are characteristic of hemorrhagic 
tissue, and, in this respect, of importance for our diagnosis. 

We also find peculiar crystals that are only found in the 
villous tissue, and therefore pathognomonic. They are small, 
colorless, round rosettes, that are dissolved in concentrate 
acid and alkalies only. They are probably oxalate of lime, 
as effervesce when treated as oxalate of calcium is in 
examining calculi. 

If the urine is highly alkaline the villi are encrusted with 
urate of ammonium and the earthy phosphates. The pa- 
tient then feels as if gravel were passing through the urethra, 
and usually demands an examination for stone. 

3. Calculi of the Bladder. 

If stones are present in the bladder we usually find 
blood in the urine, after exercise, that disappears again 
when the patient is at rest. The urine passed during the 
day is more bloody than that passed during the night, in 
contradistinction with other forms of haematuria where the 
blood is unchanged by time. 

Calculi frequently cause cystitis. If they are small and 
smooth, as uric acid, for instance, they cause catarrh of the 
first degree. If the calculus is larger or possesses a rough 
surface (phosphates, oxalate), then it is accompanied by 
catarrh of the second degree. Hemorrhage into the bladder 
also depends upon the conformation of the surface. 

The reaction of the urine depends upon the amount of 
catarrh present. 

It is of importance to determine whether an affection of 
the kidney is also present [see "mixed albumin uria"]. If this 
25 



194 EXAMINATION OF THE URINE. 

is detected it is probable that the same process is going on 
in the kidney as in the bladder. 

Determination of the chemical composition of the calculus 
depends upon the chemical properties of the urine. The 
amorphous and crystallized combinations found in the sedi- 
ment form the outer layers of the calculus. The nucleus, 
in the majority of cases, consists ot uric acid (90%). 

4. Diseases of the Urethra and the Prostate Gland. 

These do not always produce marked changes in the urine. 
Acute and chronic prostatitis as well as hypertrophy of the 
prostate gland are usually complicated by catarrh of the 
bladder of the first and second degree. In prostatitis we 
usually have cystitis of the first degree; in hypertrophy, 
either of the first or of the second to correspond with the 
amount of retention of urine. When the prostata is very 
much hypertrophied we usually find spermatozoa in the sed- 
iment. It seems that the increase in glandular tissue com- 
presses and destroys the muscular tissue of the ejaculatory 
duct, thus preventing its closure. 

In spermatorrhea the urine is either neutral or alkaline. 
Upon boiling it becomes cloudy and earthy phosphates are 
precipitated, dissolving upon the addition of acetic acid 
(Hellers bone-earth) ; albumen is not present. Besides nu- 
merous spermatozoa we find in the sediment, calcium carbo- 
nate, crystalline calcium phosphate and sometimes the triple 
phosphate. Before making the diagnosis it is necessary to 
know whether the urine has been passed immediately before 
an emission or coitus or not, as we always find spermatozoa 
in the urine after an ejaculation. 

In acute and chronic gonorrhoea we find pus corpuscles 
and single cylindrical epithelia from the urethra. 



GONORRHOEA. 



*95 



If the urine does not permit the diagnosis of the origin of 
the pus, then it will be well to collect the urine in two ves- 
sels (Thompson). That passed first will contain all the pus 
from the urethra — that passed afterward will contain the 
secretions from the bladder or pelvis of the kidney. 

The threads of gonorrhoea that may be found after normal 
cases of gonorrhoea, are commonly formed in the accessory 
glands of the urethra. It is only the very long threads, very 
rare, that may be formed in the urethra. These threads oc- 
cur in two varieties — the one, thick, long and possessing at 
one end a head-like dilatation; the other, thin and short and 
without the dilatation. The former coming from the prostatic 
portion of the urethra, the latter from Littres' glands. 

Under the microscope they consist of pus corpuscles, 
mixed with cylindrical epithelia and imbedded in an homo- 
geneous substance. 

In croup of the urethra, small, white, membranous or 
tubular structures are passed with the urine, together with 
pus and blood. 



END. 








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